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The National Center on 
Addiction and Substance Abuse 
at Columbia University 



^COLUMBIA 



633 Third Avenue 

New York, NY 10017^706 

phone 212 841 5200 
fax 212 956 8020 
www.casacolumbia.org 

Hoard qf Directors 

Jeffrey B. Lane 
Chairman 

Joseph A. CaJifano, Jr. 

Founder and Chair Emeritus 

William H. Foster, Ph.D. 

President and CEO 

Lee C. Bollinger 

Ursula VI. Hums 

Columba Bush 

Kenneth I. Chenault 

Peter R. Dolan 

Victor F. Gan/.i 

Melioda B. Hilriebrand 

Ralph Izzo, Ph.D. 

Gene F. Jankowski 

David A. Kessler, M.D. 

Jeffrey B. Kindler 

.Alan I. Leshner, Ph.D. 

Rev. Edward A. Malloy, CSC 

Doug Morris 

Bruce F,. Mosler 

Manuel T. Pacheco, Ph.D. 

Joseph J. Plumeri 

Jim Bamstad 

Shari E. Redstone 

F. John Rosenwald, Jr. 

Michael I. Roth 

Mara Burros Sandler 

Michael P. Schulhof 

Louis W. Sullivan, M.D. 

John J. Sweeney 

Clyde C. Higgle 



Directors Emeritus 

James E. Burke (1992-1997) 
Jamie Lcc Curtis (2001-2009) 
Jamie Dhnon (1995-2009) 
Mary Fislier (1996 2005) 
Betty Ford (1992-1998) 
Douglas A. Fraser (1992-2003) 
Barbara C. Jordan (1992-1996) 
Leo Kehnenson (1998 2006) 
Donald R. Keough (1992 2010) 
LaSalle Lefiall (1992-2001) 
Nancy Reagan (1995-2000) 
Linda J. Rice (1992-1996) 
George Bupp (1993-2002) 
Michael I. Sovern (1992-1993) 
Frank G. Wells (1992-1994) 
Michael A. Wiener (1997-2009) 



Addiction Medicine: 

Closing the Gap between Science and Practice 



June 2012 



Funded by: 

The Annenberg Foundation 

The Diana, Princess of Wales Memorial Fund and The Franklin 

The New York Community Trust 

Adrian and Jessie Archbold Charitable Trust 



Board of Directors 



Lee C. Bollinger Rev. Edward A. Malloy, CSC 

President, Columbia University President Emeritus, University of Notre Dame 

Ursula M. Burns Doug Morris 

Chairman and CEO, Xerox Corporation CEO, Sony Music Entertainment 



Columba Bush 

Former First Lady of Florida 

Joseph A. Califano, Jr. 

Founder and Chairman Emeritus, CAS A Columbia 

Kenneth I. Chenault 

Chairman and CEO, 
American Express Company 

Peter R. Dolan 

Chairman, ChildObesityl80 

William H. Foster, Ph.D. 

President and CEO, CASA Columbia 

Victor F. Ganzi 

Chairman of the Board PGA Tour 
Melinda B. Hildebrand 
Ralph Izzo, Ph.D. 

Chairman of the Board, CEO and President, 
Public Service Enterprise Group, Inc. (PSEG) 

Gene F. Jankowski 

President, CBS Broadcasting, Retired 

David A. Kessler, M.D. 
Jeffrey B. Kindler 

Jeffrey B. Lane 

Chairman, CASA Columbia 

Alan I. Leshner, Ph.D. 

CEO, Executive Publisher, Science, American 
Association for the Advancement of Science 

Directors Emeritus 
James E. Burke (1992-1997) 
Jamie Lee Curtis (2001-2009) 
Jamie Dimon (1995-2009) 
Mary Fisher (1996-2005) 
Betty Ford (1992-1998) 
Douglas A. Fraser (1992-2003) 
Barbara C. Jordan (1992-1996) 
Leo- Arthur Kelmenson (1998-2006) 



Bruce E. Mosler 

Chairman, Global Brokerage, 
Cushman & Wakefield, Inc. 

Manuel T. Pacheco, Ph.D. 

President Emeritus, University of Arizona and 
University of Missouri System 

Joseph J. Plumeri 

Chairman and CEO, 
Willis Group Holdings PLC 

Jim Ramstad 

Former Member of Congress (MN-3) 

Shari E. Redstone 

President, National Amusements, Inc. 

E. John Rosenwald, Jr. 

Vice Chairman Emeritus, J.P.Morgan 

Michael I. Roth 

Chairman and CEO, The Interpublic Group 
of Companies, Inc. 

Mara Burros Sandler 

Michael P. Schulhof 

Chairman, GTI Holdings LLC 

Louis W. Sullivan, M.D. 

President Emeritus, Morehouse School of Medicine 
John J. Sweeney 
Clyde C. Tuggle 

Senior Vice President, Chief Public Affairs and 
Communications Officer, The Coca-Cola Company 

Donald R. Keough (1992-2010) 

LaSalle D. Leffall, Jr., M.D., F.A.C.S. (1992-2001) 

Nancy Reagan (1995-2000) 

Linda Johnson Rice (1992-1996) 

George Rupp, Ph.D. (1993-2002) 

Michael I. Sovern (1992-1993) 

Frank G. Wells (1992-1994) 

Michael A. Wiener (1997-2009) 



Copyright ©2012. All rights reserved. May not be used or reproduced without the express written permission of The National Center 
on Addiction and Substance Abuse at Columbia University. 



The CASA Columbia National Advisory Commission on Addiction Treatment 



Drew E. Altman, PhD (Chair) 
President and Chief Executive Officer 
The Henry J. Kaiser Family Foundation 

Harvey V. Fineberg, MD, PhD 
President 

Institute of Medicine 
Mark S. Gold, MD 

University of Florida College of Medicine 
and McKnight Brain Institute 
Departments of Psychiatry, Neuroscience, 
Anesthesiology, Community Health & Family 
Medicine 

Chairman, Department of Psychiatry 

Shelly F. Greenfield, MD, MPH 

Chief Academic Officer, McLean Hospital 

Professor of Psychiatry, 

Harvard Medical School 

Director, Clinical and Health Services Research 
and Education 

Division on Alcohol and Drug Abuse, 
McLean Hospital 

Elizabeth R. Kabler 
President 

Rosenstiel Foundation 

Myles V. Lynk, JD 

Peter Kiewit Foundation 

Professor of Law and the Legal Profession 

Faculty Fellow, Center for Law, Science & 

Innovation's Program in Public Health Law 

and Policy 

Sandra Day O'Connor College of Law 
Arizona State University 



June E. Osborn, MD 

President Emerita 

Josiah Macy, Jr. Foundation 

Manuel T. Pacheco, PhD 

President Emeritus, University of Arizona 

and University of Missouri System 

The Honorable Jose R. Rodriguez 
Circuit Judge 

Ninth Judicial Circuit of Florida 

Reverend Msgr. Stephen J. Rossetti, PhD, DM in 

Clinical Associate Professor 

Associate Dean for Seminary 

and Ministerial Programs 

The Catholic University of America, 

The School of Theology and Religious Studies 

Former President and Chief Executive Officer 

Saint Luke Institute, Inc. 

Leonard D. Schaeffer 
Judge Robert Maclay Widney 
Chair & Professor 
University of Southern California 

Steven A. Schroeder, MD 

Distinguished Professor of Health and Health 

Care, Department of Medicine 

Director, Smoking Cessation Leadership Center 

University of California, San Francisco 

Louis W. Sullivan, MD 
President Emeritus 
Morehouse School of Medicine 



Table of Contents 



Foreword and Accompanying Statement by Drew Altman, PhD i 

I. Introduction and Executive Summary 1 

The CASA Columbia Study 4 

Key Findings 6 

Addiction Is a Brain Disease 6 

As with Other Health Conditions, There Are Clear Risk Factors for 

the Development of Addiction 7 

Addiction Frequently Co-Occurs with Other Health Conditions 7 

Addiction Can Be a Chronic Disease 7 

A Lack of Standardized Terminology Compromises Effective Interventions 7 

Multiple Addictive Substances and Behaviors Frequently Are Involved in 

Risky Use and Addiction 7 

Public Attitudes about the Causes of Addiction Are Out of Sync with the Science 8 

Physicians and Other Health Care Providers Should Be on the Front Line for 

Addressing this Disease 8 

Screening and Intervention Are Effective at Addressing 

Risky Substance Use and Forestalling Addiction 9 

Effective Therapies to Treat and Manage Addiction Exist 9 

The Importance of Tailored Interventions and Treatment 10 

Public Attitudes about Addiction Treatment Reflect the Prevailing 

Non-Medical Approach to Addiction Care 10 

Most People in Need of Treatment Do Not Receive It 10 

Most Referrals to Publicly Funded Treatment Come from the 

Criminal Justice System 1 1 

Less than Half of Treatment Admissions Result in Treatment Completion 12 

Patients Face Formidable Barriers to Receiving Addiction Treatment 12 

The Spending Gap 12 

Most Funding for Addiction Treatment Comes from Public Sources 13 

The Education, Training and Accountability Gap 13 

The Profound Disconnect between Evidence and Practice 13 

Recommendations and Next Steps 14 

Reform Health Care Practice 14 

Use the Leverage of Public Policy to Speed Reform in Health Care Practice 15 

II. What Is Addiction? 19 

Addiction Is a Brain Disease 20 

The Risk Factors for Addiction 22 

Genetic Risks 22 

Biological Risks 23 

Psychological Risks 23 

Environmental Risks 23 

Early Initiation of Use 24 

Risky Use and Addiction Frequently Co-Occur with Other Health Conditions 24 

Addiction Can Be a Chronic Disease 25 



Models for Understanding Addiction 26 

Evolving Approaches to Addressing Addiction 26 

Defining the Terms 29 

The Continuum of Substance Use 29 

Public Attitudes about Addiction 34 

Perceived Causes of Addiction 35 

III. Prevalence and Consequences 39 

Defining the Problem 40 

Risky Substance Users 41 

Risky Tobacco Use 43 

Risky Alcohol Use 44 

Risky Illicit Drug Use 46 

Risky Use of Controlled Prescription Drugs 47 

Addiction 48 

Special Populations 5 1 

Pregnant Women 5 1 

Adolescents and Young Adults 51 

Older Adults 52 

Co-Occurring Disorders 52 

Members of the Military Exposed to Combat 53 

Involvement in the Justice System 55 

Consequences of Risky Substance Use and Untreated Addiction 55 

Tobacco 58 

Alcohol 59 

Illicit Drugs 60 

Controlled Prescription Drugs 61 

IV. Screening and Early Intervention 63 

The Need for Patient Education, Screening and Intervention throughout the Lifespan ....64 

Childhood and Adolescence 64 

Young Adulthood 65 

Middle and Later Adulthood 65 

Attending to Co-Occurring Conditions 66 

Patient Education and Motivation 66 

Screening 66 

Laboratory Tests 68 

Brief Interventions and Treatment Referrals 69 

Tobacco 69 

Alcohol and Other Drugs 70 

Effectiveness of Screening and Brief Interventions 71 

Tobacco 72 

Alcohol 72 

Other Drugs 73 

Implementing Screening and Brief Interventions in Health Care and Other Settings 74 

Primary Care 74 

Emergency and Trauma Care 76 

Health Care for Pregnant Women 77 



Mental Health Care 78 

Dental Care 78 

Pharmacies 78 

High School, College and University Settings 78 

Justice Settings 79 

The Workplace 80 

Government-Funded Social Service Systems 81 

Barriers to Effective Implementation of Screening and Brief Interventions 81 

Insufficient Training 81 

Competing Priorities/Insufficient Resources 82 

Inadequate Screening Tools 83 

V. Treatment and Management of Addiction 85 

A Comprehensive Approach to Treatment 86 

Assessment 87 

Stabilization 88 

Cessation of Use 88 

Detoxification 89 

Acute Care 92 

Pharmaceutical Therapies 92 

Psychosocial Therapies 102 

Combined Therapies 104 

Nutrition and Exercise 106 

Chronic Disease Management 107 

Medically Supervised Disease Management 107 

Case Management 108 

Support Services 109 

Mutual Support Services 109 

Auxiliary Support Services 113 

The Use of Technology in Addiction Treatment and Disease Management 1 14 

Public Attitudes about Addictive Substances and the Need for Addiction Treatment.... 1 14 
Perceptions of the Relative Need for Treatment Based on Substance of Addiction .1 14 

Perceptions of the Goals of Treatment 115 

Perceptions of the Types of Interventions that Constitute Treatment 116 

Perceptions of the Effectiveness of Treatment 116 

VI. Tailored Treatment for Special Populations 119 

Co-occurring Medical Disorders 119 

Co-occurring Mental Health Disorders 120 

Tobacco Cessation 121 

Treatment for Addiction Involving Alcohol and Other Drugs 121 

Adolescents 122 

Tobacco Cessation 122 

Treatment for Addiction Involving Alcohol and Other Drugs 123 

Women 124 

Pregnant Women 124 

Older Adults 125 

Racial and Ethnic Minorities 126 



Individuals of Minority Sexual Orientation 126 

Veterans and Active Duty Military 127 

Individuals Involved in the Justice System 128 

Juvenile Offenders 128 

Adult Corrections 128 

VII. The Addiction Treatment Gap 131 

Most People in Need of Treatment Do Not Receive It 133 

Variations in the Treatment Gap by Primary Substance Involved 134 

Variations in the Treatment Gap by Key Patient Characteristics 135 

Regional Variations in the Treatment Gap 137 

Sources of Funding for Addiction Treatment 137 

Privately-Funded Treatment 138 

Publically-Funded Treatment 138 

Trends in Spending on Addiction Treatment 139 

Expenditures by Providers and Types of Services 139 

Treatment Admissions 141 

Treatment Referrals and Venues 142 

Treatment Completion 145 

Variations in Treatment Completion by Source of Referral 146 

Variations in Treatment Completion by Primary Substance Involved 146 

Variations in Treatment Completion by Key Patient Characteristics 146 

Link between Funding Source, Type of Service Provided and Treatment Completion ..146 

Barriers Patients Face in Accessing and Completing Addiction Treatment 147 

Misunderstanding of the Disease 147 

Negative Public Attitudes and Behaviors Toward People with Addiction 148 

Privacy Concerns 150 

Cost 151 

Lack of Information about How To Get Help 152 

Limited Availability of Services 152 

Insufficient Social Support 153 

Conflicting Time Commitments 153 

Negative Perceptions of the Treatment Process 153 

Legal Barriers 154 

Barriers to Treatment Access and Completion in Special Populations 154 

Individuals with Co-Occurring Conditions 154 

Pregnant and Parenting Women 155 

Adolescents 155 

Older Adults 156 

The Homeless 156 

Veterans and Active Duty Military 157 

Rural Populations 157 

Native Americans 158 



VIII. The Spending Gap 159 

The Rational Approach to Risky Substance Use and Addiction 159 

Costs of Our Failure to Prevent and Treat Addiction as a Medical Condition 160 

The Largest Share of Costs Falls to the Health Care System 160 

Cost Savings of Addiction Screening, Intervention and Treatment 161 

Screening and Early Intervention 162 

Addiction Treatment and Disease Management 164 

Insurance Coverage of Addiction Treatment is Limited 166 

Parity Laws 166 

The Patient Protection and Affordable Care Act of 2010 168 

Gaps in Coverage within Public and Private Insurance Plans Continue to 
Impede Comprehensive Addiction Care 169 

IX. The Education, Training and Accountability Gap 175 

The Size and Shape of the Addiction Treatment Workforce 176 

Licensing and Credentialing Requirements for Individuals who Provide 

Addiction Treatment 177 

Medical Professionals 178 

Mental Health Professionals 183 

Acupuncturists 185 

Addiction Counselors 186 

Licensure, Certification and Accreditation Requirements for Addiction Treatment 

Programs and Facilities 187 

State Licensing Requirements 188 

Federal Regulatory Requirements 189 

Accreditation Requirements 190 

Professional Staffing Requirements 191 

Treatment Service Requirements 193 

Quality Assurance Requirements 195 

X. The Evidence-Practice Gap 199 

Current Approaches to Risky Substance Use and Addiction Are Inconsistent 

with the Science and Evidence-Based Care 199 

Patient Education, Screening, Brief Interventions and Treatment Referrals 200 

Assessment, Stabilization and Acute Treatment 204 

Tailored Treatment Services 208 

Chronic Disease Management 210 

Barriers to Closing the Evidence-Practice Gap 212 

The Addiction Treatment Workforce is Not Qualified to Implement 

Evidence-Based Practices 212 

Health Professionals do not Implement Evidence-Based Addiction Care Practices .216 

Inadequate Use and Development of Pharmaceutical Treatments for Addiction 219 

Inadequate Quality Assurance 220 

Inadequate Insurance Coverage 222 

No Overarching Organizing Body for Addiction Science and Treatment 223 

Efforts to Integrate Substance Use Prevention and Treatment into 
Mainstream Medicine 223 



XL Recommendations and Next Steps 227 

Reform Health Care Practice 228 

Incorporate Screening and Intervention for Risky Substance Use, 
and Diagnosis, Treatment and Disease Management for Addiction 

into Routine Medical Practice 228 

All Medical Schools and Residency Training Programs Should Educate and 

Train Physicians to Address Risky Substance Use and Addiction 229 

Require Non-Physician Health Professionals to Be Educated and Trained to 

Address Risky Substance Use and Addiction 229 

Develop Improved Screening and Assessment Instruments 230 

Establish National Accreditation Standards for All Addiction Treatment 

Facilities and Programs that Reflect Evidence-Based Care 230 

Standardize Language Used to Describe the Full Spectrum of Substance Use and 

Addiction 230 

Use the Leverage of Public Policy to Speed Reform in Health Care Practice 231 

Condition Grants and Contracts for Addiction Services on the Provision of 

Quality Care 231 

Educate Non-Health Professionals about Risky Substance Use and Addiction 23 1 

Identify Patients at Risk in Government Programs and Services where Costs of 

Risky Use and Addiction Are High 23 1 

Develop Tools to Improve Service Quality 23 1 

License Addiction Treatment Facilities as Health Care Providers 232 

Require Adherence to National Accreditation Standards that 

Reflect Evidence-Based Care 232 

Require that All Insurers Provide Coverage for Comprehensive Addiction Care 232 

Expand the Addiction Medicine Workforce 232 

Implement a National Public Health Campaign 233 

Invest in Research and Data Collection to Improve and Track Progress in Addiction 

Prevention, Treatment and Disease Management 233 

Implement the National Institutes of Health's (NIH) Recommendation to Create a 

Single Institute Addressing Substance Use and Addiction 234 

Appendix A-Methodology 235 

Appendix B-Key Informant Interview Guide and List of Key Informants 245 

Appendix C-National Addiction Belief and Attitude Survey (NABAS) 253 

Appendix D-Survey of New York State Addiction Treatment Directors 269 

Appendix E-Survey of New York State Addiction Treatment Staff 285 

Appendix F- National Panel and National Online Survey of Members of Professional 

Associations Involved in Addiction Care 297 

Appendix G-Survey of Participants in Recovery 305 

Appendix H- Screening and Assessment Instruments 311 

Notes 325 

Bibliography 429 



Accompanying Statement by 

Drew E. Altaian, PhD, Chair, The CASA Columbia 

National Advisory Commission on Addiction Treatment 

In homes, doctors' offices, hospitals, schools, 
prisons, jails and communities across America, 
misperceptions about addiction are undermining 
medical care. Although advances in 
neuroscience, brain imaging and behavioral 
research clearly show that addiction is a 
complex brain disease, today the disease of 
addiction is still often misunderstood as a moral 
failing, a lack of willpower, a subject of shame 
and disgust. Addiction affects 16 percent of 
Americans ages 12 and older— 40 million people. 
That is more than the number of people with 
heart disease (27 million), diabetes (26 million) 
or cancer (19 million). Another 32 percent of 
the population (80 million) uses tobacco, alcohol 
and other drugs in risky ways that threaten 
health and safety. 



Like other public health and medical problems, 
we understand the risk factors for addiction. We 
have effective ways of screening for risky use 
and intervening. While as of now there is no 
cure for addiction, there are effective 
psychosocial and pharmaceutical treatments and 
methods of managing the disease. But as this 
landmark report by CASA Columbia shows in 
sharp detail, this is where the comparison with 
other health conditions ends. Unlike other 
diseases, we do little to effectively prevent and 
reduce risky use and the vast majority of people 
in need of addiction treatment do not receive 
anything that approximates evidence-based care. 

The medical system, which is dedicated to 
alleviating suffering and treating disease, largely 
has been disengaged from these serious health 
care problems. The consequences of this 
inattention are profound. America's failure to 
prevent risky use and effectively treat addiction 
results in an enormous array of health and social 
problems such as accidents, homicides and 
suicides, child neglect and abuse, family 
dysfunction and unplanned pregnancies. CASA 
Columbia estimates that risky substance use and 



-i- 



addiction are this nation's largest preventable 
and most costly health problems, accounting for 
one third of hospital inpatient costs, driving 
crime and lost productivity and resulting in total 
costs to government alone of at least $468 
billion each year. 

In many ways, America's approach to addiction 
treatment today is similar to the state of 
medicine in the early 1900s. In 1908, the 
Council on Medical Education of the American 
Medical Association turned to the Carnegie 
Foundation for the Advancement of Teaching to 
conduct a survey of Medical Education in the 
U.S. That survey, which became known as the 
Flexner Report, was led by Abraham Flexner 
who famously observed of the discrepancy 
among physicians' qualifications, "there is 
probably no other country in the world in which 
there is so great a distance and so fatal a 
difference between the best, the average and the 
worst." This CASA Columbia report identifies a 
similar gulf in the knowledge and practice skills 
of addiction treatment providers today. The 
education and training of persons providing 
addiction treatment vary considerably by state. 
In many cases, entry requirements for the 
profession are minimal in terms of education and 
are based on apprenticeship models rather than 
on science-based instruction. 

Flexner noted that the turn of the 19 th to 20 th 
century was a time of scientific progress in the 
understanding of disease and its treatment; 
however, due to the lack of a standardized and 
rigorous education for physicians, society reaped 
"but a small fraction of the advantage which 
current knowledge has the power to confer." 
Similarly, 1 00 years later, advances in science 
and medicine have drawn a much clearer picture 
of addiction-including its causes, correlates and 
how to treat it— yet we are woefully unprepared 
to apply this evidence to practice. Our medical 
professionals are not trained to look for risky use 
and addiction or to intervene or treat the disease. 
Without medical attention, the disease 
progresses, forcing doctors to expend valuable 
resources treating the more than 70 other 
conditions requiring medical attention that result 
from substance use and addiction, while 
taxpayers shoulder the costs of these health and 



other social consequences. This neglect by the 
medical system has led to the creation of a 
separate and unrelated system of addiction care 
that struggles to treat the disease without the 
resources or the knowledge base to keep pace 
with science and medicine. 

Because addiction affects cognition and is 
associated primarily with the difficult social 
consequences that result from our failure to 
prevent and treat it, those who suffer from the 
disease are poor advocates for their own health. 
And due in large part to the shame, stigma and 
discrimination attached to the disease, 
individuals with addiction and their family 
members too often are isolated in their struggle 
to understand the disease and find help. Only 
recently have we begun to see those affected by 
the disease working to raise awareness in ways, 
for example, that families of breast cancer 
victims have done. But these efforts are small, 
challenged by public misunderstanding and have 
failed to raise sufficient funding for needed 
research. 

Even individuals who can transcend the stigma 
face significant barriers to receiving effective 
care, and this report paints a dismal picture of a 
treatment 'non-system. ' While almost half of 
Americans say they would go to their health care 
providers for help, most doctors are uninformed 
about this disease and rarely are equipped to 
offer a diagnosis, provide treatment or connect 
patients with appropriate specialty care. 
Insurance coverage varies widely. Services 
rarely are tailored to individual needs and are 
based primarily on an acute care model rather 
than recognizing the chronic nature of the 
disease. There are no national standards of care. 
Patients face a patchwork of treatment programs 
with vastly different approaches; many offer 
unproven therapies and little medical 
supervision. Some promise "one time" fixes; 
others offer posh residential treatment at 
astronomical prices with little evidence 
justifying the cost. Even for those who do have 
insurance coverage or can pay out-of-pocket, 
there are no outcome data reflecting the quality 
of treatment providers so that patients can make 
informed decisions. 



-n- 



This report focuses long overdue attention on the 
disease of addiction. It clarifies the important 
difference between this disease and risky use of 
addictive substances; identifies the human and 
economic costs of our current approach to these 
health problems; and documents the breadth of 
available knowledge on how to prevent risky use 
and treat addiction. 

As our nation struggles to reduce skyrocketing 
health care costs, there are few targets for cost 
savings that are as straightforward as preventing 
and treating risky substance use and addiction. 
This report shows that modest public health 
interventions and relatively inexpensive 
addiction therapies, compared with other 
medical treatments, would reduce this burden 
significantly. 

The report calls for modernizing addiction 
treatment-to harness the scientific knowledge 
we have acquired to prevent risky use and treat 
this disease. This report is a call to action. Like 
the Flexner Report a century ago, it shines a 
bright light on the problem and offers a roadmap 
for action. Addiction Medicine: Closing the Gap 
between Science and Practice represents more 
than five years of intensive research, and draws 
on policy and treatment research conducted by 
CASA Columbia over two decades and on a 
wide body of scientific, clinical and policy 
research conducted by others. This major 
undertaking was the result of the work of a large 
team of dedicated individuals and institutions 
and was conducted with the able advice and 
counsel of The CASA Columbia National 
Advisory Commission on Addiction Treatment 
which 1 had the privilege to chair. The 
Commission includes an impressive group of 
individuals knowledgeable about the many 
aspects of substance use and addiction in 
America today. We are grateful for their expert 
assistance. 

The project was made possible by the generous 
financial support of The Annenberg Foundation; 
The Diana, Princess of Wales Memorial Fund 
and The Franklin Mint; The New York 
Community Trust; and the Adrian and Jessie 
Archbold Charitable Trust. 



Peter D. Hart Research Associates conducted the 
National Addiction Belief and Attitude Survey 
for this report; Survey Research Laboratory 
(SRL) of the University of Illinois at Chicago 
administered the survey of New York State 
addiction treatment providers. We are grateful 
to Karen Carpenter-Palumbo, former director of 
the New York State Office of Alcoholism and 
Substance Abuse Services (OASAS) for helping 
to make the New York State survey possible. 

We thank the following organizations which 
generously helped connect CASA Columbia 
with treatment providers who participated in a 
national online survey of members of 
professional associations involved in addiction 
care: The American Academy of Addiction 
Psychiatry (AAAP); the American Association 
for the Treatment of Opioid Dependence 
(AATOD); the American Psychological 
Association (APA); the American Society of 
Addiction Medicine (ASAM); the Association 
for the Treatment of Tobacco Use and 
Dependence (ATTUD); NAADAC, the 
Association for Addiction Professionals; the 
National Association of Addiction Treatment 
Providers (NAATP); the National Association of 
County Behavioral Health and Developmental 
Disability Directors (NACBHDD); the National 
Council for Community Behavioral Healthcare 
(National Council); the State Associations of 
Addiction Services (SAAS); and Treatment 
Communities of America (TCA). Also, we 
thank the following organizations for connecting 
us with individuals in long-term recovery for 
CASA Columbia's online survey of this 
population: Hazelden, Freedom Institute, Faces 
and Voices of Recovery, Betty Ford Center, 
National Council on Alcoholism and Drug 
Dependence, Inc. (NCADD), Treatment 
Communities of America (TCA), Alcoholism 
and Substance Abuse Providers of New York 
State, Inc. (ASAP) and an anonymous treatment 
program alumni group. Finally, we are grateful 
to the 1 76 key informants who shared their 
insight and recommendations. 

Susan E. Foster, MSW, CASA Columbia's Vice 
President and Director of Policy Research and 
Analysis, was the principal investigator and staff 
director for this effort. The senior research 



-iii- 



manager was Linda Richter, PhD, Associate 
Director of the Division and CASA Columbia 
Scholar. The data collection and analysis was 
conducted by CASA Columbia's Data Analysis 
Center (SADAC SM ), headed by Roger Vaughan, 
DrPH, CASA Columbia Fellow and Professor of 
Clinical Biostatistics, Department of 
Biostatistics, Mailman School of Public Health 
at Columbia University, and associate editor for 
statistics and evaluation for the American 
Journal of Public Health. He was assisted by 
Elizabeth Peters and Sarah Tsai, MA. Emily 
Feinstein, JD, senior policy analyst, assisted 
with the research and writing. Other research 
staff members who worked on the project are: 
Nina Lei, Mark Stovell, Akiyo Kodera, Dina 
Feivelson, PhD, Gina Hijjawi, PhD, Harold 
Wenglinsky, PhD, Swapna Reddy, JD, Kristen 
Keneipp, MHS, Nabil Ansari and Sarah 
Blachman. David Man, PhD, MLS, is CASA 
Columbia's librarian; he was assisted by Barbara 
Kurzweil. Jennie Hauser managed the 
bibliographic database and Jane Carlson handled 
administrative details. 

While many individuals and institutions 
contributed to this effort, the findings and 
opinions expressed herein are the sole 
responsibility of CASA Columbia. 



Chapter I 

Introduction and Executive Summary 



A large and growing body of scientific research 
has demonstrated clearly that addiction 
involving nicotine, alcohol, illicit drugs and 
controlled prescription drugs is a complex brain 
disease. 1 It affects 15.9 percent of the United 
States population ages 12 and older (40.3 
million) 1 2 — more than the share of the 
population with heart disease,* diabetes or 
cancer. 3 Another 3 1 .7 percent of the population 
(80.4 million), while not addicted, engages in 
risky use § of addictive substances in ways that 
threaten health and safety. 4 



In this report, we have used the general term 
addiction to apply to those who meet criteria for past- 
month nicotine dependence based on the Nicotine 
Dependence Syndrome Scale (NDSS) and those who 
meet diagnostic criteria for past year alcohol and/or 
other drug abuse or dependence (excluding nicotine) 
in accordance with the Diagnostic and Statistical 
Manual of Mental Disorders (DSM-IV). (The DSM, 
the most widely accepted diagnostic system in the 
U.S. for such conditions, refers to substance abuse 
and substance dependence collectively as substance 
use disorders. The diagnostic criteria for nicotine 
dependence in the NDSS parallel those of the DSM- 
IV). This definition is consistent with the current 
move to combine abuse and dependence into an 
overarching diagnosis of addiction in the upcoming 
DSM-V. The term addiction also has been used in 
reference to compulsive behaviors involving eating, 
gambling and other activities that affect the brain's 
reward system and which may develop independent 
of or in combination with other manifestations of 
addiction. This report, however, focuses only on 
addiction involving nicotine, alcohol and other drugs. 

* This estimate excludes the institutionalized 
population, for which rates of addiction are higher. 

* Includes coronary heart disease, angina pectoris, 
heart attack or any other heart condition or disease, 
excluding hypertension and stroke. 

§ Risky users of addictive substances are defined in 
this report as those who currently use tobacco 
products, exceed the U.S. Department of Agriculture 
(USDA) Dietary Guidelines for safe alcohol use, 
misuse controlled prescription drugs, use illicit drugs, 
or engage in some combination of these forms of 
substance use, but do not meet clinical diagnostic 
criteria for addiction. (See page 5.) 



-1- 



Addiction and risky use constitute the largest 
preventable and most costly health problems 
facing the U.S. today. 5 It is estimated that more 
than 20 percent of deaths in the U.S. are 
attributable to tobacco, alcohol and other drug 
use. 6 Addiction and risky use cause or 
contribute to more than 70 other conditions 
requiring medical care, including cancer, 
respiratory disease, cardiovascular disease, 
HIV/AIDS, pregnancy complications, cirrhosis, 
ulcers and trauma. 7 They also drive and 
contribute to a wide range of costly social 
consequences, including crime, accidents, 
suicide, child neglect and abuse, family 
dysfunction, unplanned pregnancies and lost 
productivity. 8 Costs of addiction and risky 
substance use to government alone total at least 
$468 billion each year. 9 

While both addiction and risky use of addictive 
substances contribute to these consequences, 
they are very different conditions. Addiction is 
a disease and, like other diseases, it can and 
should be diagnosed and treated in the context of 
the medical system, using available evidence- 
based practices. Risky use of addictive 
substances is a public health problem and tools 
are available for a wide range of professionals in 
the health, social services, education, criminal 
justice and other sectors to screen for it and 
intervene to reduce it and its consequences, 
including the potential development of 
addiction. 

Despite the prevalence of these conditions, the 
enormity of the consequences that result from 
them and the availability of effective solutions, 
screening and early intervention for risky 
substance use is rare and the vast majority of 
people in need of addiction treatment do not 
receive anything that approximates evidence- 
based care. Nine out of 10 people (89. 1 percent) 
who meet diagnostic criteria for addiction 



Involving interdisciplinary teams of physicians (of 
multiple medical specialties and subspecialties), 
nurses, physician assistants, nurses and nurse 
practitioners and graduate-level clinical mental health 
professionals (psychologists, social workers, 
counselors), working collaboratively with auxiliary 
and support personnel. 



involving alcohol and drugs other than nicotine 
report receiving no treatment' at all; 10 as a 
society, we do not even collect information on 
the number of people receiving treatment for 
addiction involving nicotine. There is no other 
disease that affects so many people, has such 
far-reaching consequences and for which there is 
such a broad range of effective interventions and 
treatments that is as neglected as the disease of 
addiction. 

This report documents the significant body of 
evidence defining and describing the disease of 
addiction and the risky use of addictive 
substances. It reveals the size and shape of the 
populations in need of screening, intervention 
and treatment. It reviews the evidence of 
effective screening, intervention, diagnostic, 
treatment and disease management tools and 
therapies. It outlines the consequences and costs 
of our failure to prevent risky substance use and 
treat addiction effectively. Finally, it examines 
the profound gaps between those who need 
treatment and those who receive it, and between 
the services they receive and what constitutes 
quality care. 

Key factors driving these gaps include: 

• Inadequate Integration of Addiction Care 
into Mainstream Medical Practice: 

Addiction prevention and treatment are for 
the most part removed from routine medical 
practice. 11 In spite of the fact that about 80 
percent of Americans 1 visited at least one 
physician or other health care professional in 



* Treatment is defined in this report as psychosocial 
and pharmaceutical therapies. Detoxification, mutual 
support programs, peer counseling, other support 
services (including religious-based counseling) and 
services received in an emergency department are 
excluded from the definition. Services provided in 
prison or jail settings also are excluded since they 
cannot be identified in the data sources used for this 
analysis; furthermore, in CAS A Columbia's 2010 
report {Behind Bars Update: Substance Abuse and 
America 's Prison Population), more than 70 percent 
of those receiving addiction-related services in 
prisons and jails received support services rather than 
any form of professional treatment. 

* Ages 1 8 and older. 



-2- 



the past year, and more than two-thirds of 
people with addiction are estimated to be in 
contact with a primary or emergency care 
physician about twice a year, 13 most 
physicians and other health professionals 
do not identify or diagnose the disease or 
know what to do with patients who present 
with identifiable and treatable signs and 
symptoms. And, unlike other diseases, 
physicians too often lack access to available, 
trained and certified addiction physician 
specialists for consultation or referral. 
Instead of addressing addiction, the medical 
field primarily has focused its efforts on 
treating the secondary and tertiary 
complications of addiction, allowing the 
public health epidemic to advance 
unchecked. Furthermore, whereas the main 
criterion for determining whether health care 
services should be provided to patients in 
mainstream medicine is the principle of 
medical necessity, 14 patients needing 
addiction treatment may face stringent 
eligibility criteria for treatment entry, 
including insurance benefit restrictions, 
limited availability of treatment slots, long 
waiting lists, lack of child care and the 
requirement to comply with all rules and 
treatment protocols. 15 There simply is no 
other disease where appropriate medical 
treatment is not provided by the health care 
system and where patients instead must turn 
to a broad range of practitioners largely 
exempt from medical standards. 

• Inadequate Education and Training of 
Addiction Treatment Providers: The 

majority of those who currently make up the 
addiction treatment provider workforce are 
not equipped with the knowledge, skills or 
credentials necessary to provide the full 
range of evidence-based services to treat the 
disease. 



The term "health professional" as used in this report 
includes medical professionals (physicians, physician 
assistants, nurses and nurse practitioners, dentists, 
pharmacists) and graduate-level clinical mental 
health professionals (psychologists, social workers, 
counselors). 



> Addiction counselors, who make up the 
largest share of providers of addiction 
treatment services, provide care for 
patients with a medical disease yet they 
are not required to have any medical 
training and most states do not require 
them to have advanced education of any 
sort.' 

> Physicians and other medical 
professionals, who make up the smallest 
share of providers of addiction treatment 
services, receive little education or 
training in addiction science, prevention 
and treatment. 



• Inadequate Accountability for Addiction 
Treatment Providers: Addiction treatment 
providers, facilities and programs are not 
adequately regulated or held accountable for 
providing treatment consistent with medical 



Only six states require a bachelor's degree and only 
one state requires a master's degree. 



Published in the 

American Journal of Public Health 
July, 1919 

There is urgent need for widespread and early 
education of the medical profession, 
legislators, administrative authorities and laity 
into the facts of addiction disease. . . 

As a definite clinical entity of physical 
disease, addiction is practically untaught in 
the school and unappreciated by the average 
medical man. . . 

In the light of available clinical information 
and study and in the light of competent 
laboratory research we are forced as a 
profession to admit that we have not treated 
our addiction sufferers with sympathetic 
understanding and clinical competency and 
that the blame for the past failure to control 
the [narcotic] drug problem rests largely upon 
the educational inadequacy of our medical 
profession, and institutions of scientific and 
public health education. 16 

-Ernest S. Bishop, MD, FACP 



-3- 



standards and proven treatment practices. 
The credentials of treatment providers vary 
dramatically from state to state and from 
program to program. Compounding the 
problem, quality assurance standards that do 
exist focus more on administrative processes 
than on measureable patient outcomes. 

• Inadequate Allocation of Financial 
Resources: Financial investments in 
addressing addiction and risky substance use 
are aimed disproportionately at coping with 
their costly health and social consequences 
rather than at the effective implementation 
of available prevention, intervention and 
treatment approaches. In 2010, only 1.0 
percent ($28.0 billion) of total health care 
costs went to treating the disease of 
addiction. 17 Spending on addiction 
treatment disproportionately falls to the 
public sector. In contrast to the role of 
private insurance in general health care 
spending-where it covers 54.4 percent of 
costs-private insurers cover only 20.8 
percent of the costs of addiction treatment, 
and the private share has been decreasing. 18 

This profound gap between the science of 
addiction and current practice related to 
prevention and treatment is a result of decades 
of marginalizing addiction as a social problem 
rather than treating it as a medical condition. 
Much of what passes for "treatment" of 
addiction bears little resemblance to the 
treatment of other health conditions. Much of 
what is offered in addiction "rehabilitation" 
programs has not been subject to rigorous 
scientific study and the existing body of 
evidence demonstrating principles of effective 
treatment has not been taken to scale or 
integrated effectively into many of the treatment 
programs operating nationwide. This is 
inexcusable given decades of accumulated 
scientific evidence attesting to the fact that 
addiction is a brain disease with significant 
behavioral components for which there are 
effective interventions and treatments. It also is 
unfair to the thousands of addiction counselors 
who struggle, in the face of extreme resource 
limitations and no medical training, to provide 



help to patients with the disease of addiction and 
numerous co-occurring medical conditions. 

America's tendency to frame risky use of 
addictive substances and addiction as the same 
issue and as moral or social problems has 
resulted in an unmitigated failure on the part of 
policymakers and the health care community to 
educate the public about these health problems 
in ways that can help prevent them and to offer 
effective interventions and treatments that match 
those offered for other health conditions; instead 
the focus has weighed heavily toward law 
enforcement. The end result is that we have 
declared war on drugs rather than mounting a 
rational approach to prevention, treatment and 
finding a cure for the disease of addiction. We 
largely have punished rather than treated those 
in need of help even though treatment for a 
disease and accountability for behavior are not 
antithetic concepts. 

It is long past time for health care practice to 
catch up with the science. Failure to do so is a 
violation of medical ethics, a cause of untold 
human suffering and a profligate misuse of 
taxpayer dollars. 

The CASA Columbia Study 

Substance use can be understood as a continuum 
ranging from having never used tobacco, alcohol 
or another drug at one end to having an 
unmanaged chronic, relapsing disease' at the 
other. (Figure LA) 



Including any use of illicit drugs or the misuse of 
controlled prescription drugs. 
f This continuum focuses on substance use; the 
category labeled addiction includes those individuals 
who meet current clinical criteria for this disease but 
does not include all individuals with addiction. 



-4- 



Figure 1 .A 

Continuum of Substance Use 

Percent of Population Age 12+ 
by Level of Substance Use* 



12.7 


25.2 


14.5 


31.7 


Never 
Used 


No 
Current 
Use 


Non- 
Risky Use 


Risky 
Use 




* Includes tobacco, alcohol, illicit drugs and misuse of 
controlled prescription drugs. 

Source: CASA Columbia analysis of The National Survey on 
Drug Use and Health (NSDUH), 201 0. 



Guidelines for safe alcohol use/ 20 misuse 
controlled prescription drugs, 5 use illicit 
drugs" 21 or engage in some combination of 
these forms of substance use but do not 
meet clinical diagnostic criteria for 
addiction. Risky use can result in 
devastating and costly health and social 
consequences including the disease of 
addiction. Risky users are targets for public 
health efforts aimed at reducing risky use 
and for health professionals' efforts to 
prevent risky use from progressing to the 
disease of addiction. Approximately one- 
third (31.7 percent) of the U.S. population 
ages 12 and older (80.4 million people) are 
risky substance users. 22 



While this report focuses primarily on those with 
the disease of addiction, it makes an important 
distinction between addiction and risky use of 
addictive substances: 

• Those with the active disease of addiction* 
are defined in this report as meeting the 
clinical diagnostic criteria for past month 
nicotine dependence or past year alcohol 
and/or other drug abuse or dependence. 
Individuals who meet diagnostic criteria for 
addiction are targets for appropriate, 
evidence-based clinical interventions by 
physicians and other health professionals. 
Addiction afflicts 15.9 percent of the U.S. 
population ages 12 and older (40.3 million 
people). 19 

• Risky users of addictive substances are 
defined in this report as those who currently' 
use tobacco products, exceed the U.S. 
Department of Agriculture (USDA) Dietary 



Available data allow us to include only those who 
meet behavioral criteria in accordance with the 
diagnostic standards, meaning in most cases that their 
disease is not currently being managed. Individuals 
who have the disease of addiction but do not meet 
diagnostic criteria for past month (nicotine) or past 
year (alcohol and other drug) addiction are not 
included. 

1 In the past 30 days. 



1 The U.S. Department of Agriculture Dietary 
Guidelines for safe alcohol use are no more than one 
drink a day for women, no more than two drinks a 
day for men and no alcohol consumption for: 
(1) persons under the age of 21; (2) pregnant women; 
(3) individuals who cannot restrict their drinking to 
moderate levels; (4) individuals taking prescription or 
over-the-counter medications that can interact with 
alcohol; (5) individuals with certain specific medical 
conditions (e.g., liver disease, hypertriglyceridemia, 
pancreatitis); and (6) individuals who plan to drive, 
operate machinery, or take part in other activities that 
require attention, skill or coordination or in situations 
where impaired judgment could cause injury or death 
(e.g., swimming). Due to data limitations, we were 
unable to include categories 4-6 in our calculation of 
risky drinkers. 

§ For data analysis purposes, the national survey 
examined for this report defines misuse of controlled 
prescription medications more generally as "taking a 
controlled prescription drug not prescribed for you or 
taking it in a manner not prescribed for the 
experience or feeling it causes." The misuse of over- 
the-counter medications also constitutes risky use; 
however, rates of risky use in this report do not 
include the misuse of these medications since they 
are not directly measured in the national surveys that 
were analyzed for this study. 

Substances controlled (either through prohibited or 
restricted use) through the federal Controlled 
Substances Act of 1970, which created a system for 
classifying illicit and prescription drugs according to 
their medical value and their potential for misuse. In 
this analysis, illicit drugs include marijuana/hashish, 
cocaine/crack, heroin, hallucinogens, Ecstasy, 
methamphetamine and inhalants. 



-5- 



To document the research on the causes, 
consequences and extent of risky substance use 
and addiction; the available tools for effective 
interventions and for treatment; the gap between 
the need for such interventions and treatments 
and the actual standard of care; the driving 
forces behind this substantial gap; and to 
develop concrete recommendations for 
minimizing it, CASA Columbia conducted:* 

• A thorough review of more than 7,000 
scientific articles, reports, books and other 
reference materials related to the science of 
addiction, the consequences of risky use and 
addiction, the prevention of risky use and 
treatment of addiction and barriers to 
improved care (see Appendix A); 

• Secondary analysis of five national data sets 
(see Appendix A); 

• Interviews with and suggestions from 176 
leading experts in a broad range of fields 
relevant to the report, including researchers, 
physicians and other health professionals, 
other treatment providers, policymakers and 
members of professional associations, 
advocacy organizations, health insurers, 
pharmaceutical companies and organizations 
of people with the disease of addiction. 
Whereas the majority of these experts 
provided their thoughts in the context of an 
open-ended interview guide designed by 
CASA Columbia to explore key themes 
related to this project, some provided advice, 
suggestions and feedback about specific 
content to be included in this report (see 
Appendices A and B); 

• Focus groups and a national general 
population survey assessing the attitudes and 
beliefs of 1,303 adults with regard to 
addiction and its treatment: the National 
Addiction Belief and Attitude Survey 
(NABAS) (see Appendices A and C); 

• Two statewide surveys of addiction 
treatment providers in New York: one of 83 



program directors and one of 141 staff 
treatment providers (see Appendices A, D 
and E); 

• A national panel of treatment providers and 
an online survey of 1,142 members of 
professional associations involved in 
addiction care (see Appendices A and F); 

• An online survey of 360 individuals with a 
history of addiction who are managing the 
disease (see Appendices A and G); 

• An in-depth analysis of state and federal 
governments' and professional associations' 
licensing and certification requirements for 
individual treatment providers and addiction 
treatment facilities and programs, as well as 
accreditation requirements for facilities and 
programs (see Appendix A); and 

• A case study of addiction treatment in New 
York State and New York City that drew 
from the research described above and the 
findings of which are incorporated into the 
report where relevant (see Appendix A). 

Key Findings 

Addiction Is a Brain Disease 

Addiction is a complex brain disease with 
significant behavioral characteristics. 23 
Nicotine, alcohol, illicit drugs and controlled 
prescription drugs all affect the pleasure and 
reward circuitry of the brain in similar ways. 24 
Over time, continued use of these substances can 
physically alter the structure and function of the 
brain, dramatically affect judgment and 
behavior 25 and drive a compulsion to obtain and 
use them, even in the face of mounting negative 
consequences. 26 Growing evidence also points 
to structural and functional differences in the 
brain and to genetic factors that may predispose 
certain individuals to addiction. 27 



See Appendix A for a more detailed description of 
the key methodological components of the study. 



-6- 



As with Other Health Conditions, There 
Are Clear Risk Factors for the 
Development of Addiction 

Risk factors for developing addiction include a 
genetic predisposition, structural and functional 
brain vulnerabilities, psychological factors and 
environmental influences. Whereas biological, 
psychological and environmental factors— such 
as impairments in the brain's reward circuitry, 
compensation for trauma and mental health 
problems, easy access to addictive substances, 
substance use in the family or media and peer 
influences— play a large role in whether an 
individual starts to smoke, drink, or use other 
drugs, 28 genetic factors are more influential in 
determining who develops the disease of 
addiction. 29 A factor that is particularly 
predictive of risk, however, is the age of first 
use; in 96.5 percent of cases, addiction 
originates with substance use before the age of 
2 1 30 when the brain is still developing and is 
more vulnerable to the effects of addictive 
substances.* 31 

Addiction Frequently Co-Occurs with 
Other Health Conditions 

Addiction frequently co-occurs with, contributes 
to or causes a wide range of medical conditions. 
Both risky substance use and addiction cause or 
contribute to more than 70 other conditions 
requiring medical care, such as heart disease and 
cancer, 32 as well as mental health and behavioral 
disorders-including depression, anxiety, post- 
traumatic stress disorder, bipolar disorder, 
schizophrenia and other neuropsychiatric 
disorders. 33 

Addiction Can Be a Chronic Disease 

There is tremendous variation in the severity and 
course of the disease of addiction and of its 
symptoms. Some individuals may experience 
one episode in which their symptoms meet 
clinical diagnostic criteria for addiction and be 
non- symptomatic thereafter. 34 In many cases, 



These individuals also might have a predisposition 
to develop addiction, irrespective of their actual use 
of addictive substances. 



however, addiction manifests as a chronic 
disease-a persistent or long-lasting illness— 
which requires ongoing professional treatment 
and management. 35 However, very few people 
with addiction actually receive adequate, 
effective, evidence-based treatment, 36 and the 
usual approach to treatment involves brief, 
episodic interventions rather than a model based 
on long-term chronic disease management. As a 
result, high rates of relapse, while comparable to 
other chronic diseases, may be due at least in 
part to inadequate or ineffective interventions 
and treatments. 37 

A Lack of Standardized Terminology 
Compromises Effective Interventions 

Terms used to describe different levels of 
involvement with addictive substances— such as 
experimentation, use, misuse, excessive use, 
abuse, dependence and addiction—lack 
precision, obscuring important differences in the 
nature and severity of the illness and 
complicating our ability to intervene and treat it 
effectively. Even the word "treatment" lacks 
precision with regard to addiction, since 
historically it has been used to refer to a host of 
interventions, many of which are not based in 
the clinical and scientific evidence as are 
treatments for other diseases. 

Multiple Addictive Substances and 
Behaviors Frequently Are Involved in 
Risky Use and Addiction 

Traditionally, risky substance use and addiction 
have been addressed largely on a substance- 
specific basis. Growing understanding of the 
nature of risky use and the disease of addiction- 
including the risk factors, symptoms and the 
neuropsychological effects of addictive 
substances-helps to explain the significant 
proportion of risky users and those who are 
addicted who are involved with more than one 
addictive substance. Among risky substance 
users who do not meet diagnostic criteria for 
addiction, 30.6 percent are risky users of more 
than one substance. Among those who are 
addicted, 55.7 percent are risky users of one or 



-7- 



more other substances and 17.3 percent have 
addiction involving multiple substances. 38 

Emerging research also suggests that other 
behavioral manifestations of addiction (e.g., 
obesity, gambling, sexual addiction) share 
common neuropsychological and genetic 
pathways with addiction involving substances, 39 
underscoring the importance of treating the 
antecedents, manifestations and consequences of 
addiction more generally. When treatments are 
too highly focused on a specific addictive 
substance or behavior, they may not be 
addressing the actual underlying disease of 
addiction or the possibility of addiction 
substitution, where a patient may replace one 
form of addiction with another. 40 

Public Attitudes about the Causes of 
Addiction Are Out of Sync with the Science 

CASA Columbia's national survey of the 
attitudes and beliefs of adults in the U.S. with 
regard to addiction and its treatment (the 
NABAS) found that while there is public 
recognition of the role of genetics and biological 
factors in the development of addiction, 
approximately one-third of Americans continue 
to view addiction as a sign of lack of will power 
or self-control. 41 

Physicians and Other Health Professionals 
Should Be on the Front Line Addressing 
this Disease 

As with other diseases, addiction should be 
addressed within the medical system by 
physicians (including multiple medical 
specialties and sub-specialties) and a multi- 
disciplinary team of health professionals 
including physician assistants, nurses and nurse 
practitioners, and graduate level clinical 
psychologists, social workers and counselors. 

In order to treat addiction and reduce risky 
substance use and the related consequences, 
physicians and other health professionals must: 

• Understand the risk factors, how these risks 
vary across the lifespan, how risky 



substance use that does not result in 
addiction has far-reaching adverse 
consequences and that addiction frequently 
co-occurs with other health conditions; 

• Educate patients, and their families if 
relevant, about these risks, the nature of the 
disease of addiction and the adverse 
consequences of risky substance use; 

• Screen for risky substance use and 
symptoms of addiction and co-occurring 
health conditions using tools that have been 
proven to be effective; 

• Provide brief interventions when 
appropriate; and 

• Treat and manage the disease or provide 
referrals to specialty care if needed. 

Non-laboratory-based screening for risky 
substance use can be conducted by a wide range 
of trained health professionals and brief 
interventions can be conducted by physicians 
and by appropriately trained clinicians, 
supervised as necessary. All aspects of 
stabilization and treatment— including 
laboratory-based screening, assessment, acute 
care and disease management-should be 
managed by a physician, as is the case with 
other medical illnesses. Highly-trained clinical 
mental health professionals can provide 
psychosocial therapies as part of a treatment 
plan established and managed by the patient's 
physician. Case management can be provided 
by nurses and nurse practitioners, physician 
assistants and clinical mental health 
professionals if appropriately trained in 
addiction and if the services are performed under 
the supervision of a physician. Paraprofessionals 
and non-clinically trained and credentialed 
counselors can provide auxiliary services as part 
of a comprehensive treatment and disease 
management plan. 



-8- 



Referrals to specialty addiction care should be 
made to trained and credentialed addiction 
physician specialists.* 42 

Screening and Intervention Are Effective 
at Addressing Risky Substance Use and 
Forestalling Addiction 

Screening and brief interventions have been 
found to be effective tools for addressing the 
risky use of tobacco, 43 alcohol, 44 illicit drugs and 
controlled prescription drugs 45 in multiple 
settings and in many population groups 46 

A range of screening tools exist and typically 
include written or oral questionnaires and, less 
frequently, clinical and laboratory tests. 
However, most screening tools are substance 
specific; an instrument that screens for risky use 
or addiction involving all substances as a unified 
dimension-and that makes appropriate 
distinctions for age, culture and gender-has yet 
to be developed. 

For those who screen positive for risky 
substance use that does not meet the threshold of 
clinical addiction, a brief intervention-typically 
involving motivational interviewing techniques 
and substance-related education—is an effective, 
low-cost approach to reducing risky substance 
use. 47 

Effective Therapies to Treat and Manage 
Addiction Exist 

For individuals showing signs of addiction, a 
comprehensive assessment of the stage and 
severity of the disease and the provision of 
treatment and disease management are critical to 
improving health and preventing further health 
and social consequences. 48 As is true of other 
chronic diseases, while all patients with 



There are two major categories of addiction 
physician specialists: physician experts in addiction 
medicine— Diplomates of the American Board of 
Addiction Medicine (ABAM)-and physician experts 
in addiction psychiatry (psychiatrists with sub- 
specialty certification in addiction psychiatry)— 
Diplomates of the American Board of Psychiatry and 
Neurology (ABPN). 



addiction will not respond equally well to 
treatment, the provision of evidence-based 
treatment does increase the odds of success. 

Addiction is a disease that can be treated and 
managed effectively within the medical 
profession using an array of evidence-based 
pharmaceutical and psychosocial approaches. In 
accordance with standard medical practice for 
the treatment of other chronic diseases, best 
practices for the effective treatment and 
management of addiction must be consistent 
with the scientific evidence of the causes and 
course of the disease. Best practices require: 49 

• Comprehensive assessment of the extent 
and severity of the disease, determination of 
a clinical diagnosis, evaluation of co- 
occurring health conditions and the 
development of a tailored treatment plan; 

• Stabilization of the patient's condition via 
cessation of substance use and medically 
supervised detoxification, when necessary, 
as a precursor to treatment; 

• Acute Care delivered by qualified health 
care professionals via evidence-based 
pharmaceutical and/or psychosocial 
addiction treatments, accompanied by 
treatment for co-occurring health conditions; 

• Chronic Disease Management to help the 
patient maintain the progress achieved 
during acute treatment and prevent relapse. 
The process should be medically supervised 
and should involve pharmaceutical and/or 
psychosocial therapies and continued 
management of co-occurring health 
conditions as indicated; and 

• Support Services including the provision of 
auxiliary services such as legal, educational, 
employment, housing and family supports, 
as well as nutrition and exercise counseling 
and connection to mutual support programs. 



-9- 



The Importance of Tailored Interventions 
and Treatment 

Each life phase presents unique vulnerabilities 
for risky substance use and the onset of the 
disease of addiction. Recognizing these 
differences as well as the basic risk factors for 
each is critical to reducing risky substance use 
and addiction. 

Certain populations-such as pregnant women, 50 
the young 51 and the elderly 52 — are more 
vulnerable to the damaging and addictive effects 
of tobacco, alcohol and other drugs. Among 
members of the military exposed to combat, 53 
persons with co-occurring health conditions 54 
and individuals involved in the justice system 55 
the likelihood of addiction is significantly higher 
than in the general population. 

Treatment must be tailored to the particular 
stage and severity of the disease, a patient's 
overall health status, past treatments and any 
other personal characteristics and life 
circumstances that might affect patient 
outcomes. 56 These include patients with co- 
occurring health conditions, adolescents, 
women, older adults, racial and ethnic 
minorities, individuals of minority sexual 
orientation, veterans and individuals involved in 
the justice system. The research evidence 
clearly demonstrates that a one-size-fits-all 
approach to addiction treatment typically is a 
recipe for failure. 57 

Public Attitudes about Addiction Treatment 
Reflect the Prevailing Non-Medical 
Approach to Addiction Care 

CAS A Columbia's NAB AS found that although 
the American public appears to be supportive of 
assuring that individuals with addiction receive 
effective addiction treatment, public views about 
what constitutes addiction treatment do not 
comport with the science: more than half (60. 1 
percent) of respondents to the NABAS 
spontaneously offered mutual support programs 
such as AA or NA as a "treatment" intervention 
when asked what kinds of treatment come to 
mind when they think about treatment for 



addiction, despite the fact that such programs, 
while very helpful sources of support to many 
individuals with addiction, are not evidence- 
based treatments for the disease. 59 The public 
also does not seem to distinguish between risky 
substance use and the disease of addiction. 

Most People in Need of Treatment Do Not 
Receive It 

As an indicator of the lack of attention afforded 
the disease of addiction, no single national data 
source exists to compare the proportion of the 
population in need of addiction treatment 
involving any addictive substance to the 
proportion that receives such treatment. While 
about seven out of 1 people with hypertension, 
major depression or diabetes get treatment for 
their medical conditions, only about one in 1 
people with addiction involving alcohol or drugs 
other than nicotine do,* 60 (Figure l.B), leaving a 
treatment gap of 20.7 million individuals. 61 
No data exist on the treatment gap for those with 
addiction involving nicotine. The proportion of 
individuals in need of addiction treatment 
involving alcohol and drugs other than nicotine 
who actually receive it has changed little since 
2002, when 9.8 percent of those in need received 
treatment. 62 



For this comparison, CASA Columbia examined the 
referenced national survey data to determine the 
proportion of the population with each disease-those 
with diagnosed or undiagnosed hypertension (59.3 
million); those with diagnosed or undiagnosed 
diabetes (25.8 million); those who met clinical 
criteria for a major depressive episode in the past 
year and/or received professional treatment (saw a 
doctor, received medication, a combination thereof) 
(22.4 million); and those who met clinical criteria for 
addiction involving alcohol or other drugs excluding 
nicotine in the past year and/or received professional 
treatment for alcohol and/or other drugs in the past 
year (23.2 million)-who received treatment. 



-10- 



Most Referrals to Publicly Funded 
Treatment Come from the Criminal Justice 
System 

CASA Columbia's national survey conducted 
for this study found that 46.8 percent of 
respondents would turn to a health professional- 
such as their physician (27.8 percent), a health 
professional other than their primary care 
physician (19.7 percent) or a mental health 
professional (9.2 percent) —if someone close to 
them needed help for addiction. 63 However, 
only 5.7 percent of referrals to publicly funded 
treatment came from a health care provider. In 
contrast, a full 44.3 percent of the referrals to 
treatment were from the criminal justice 
system, 64 highlighting the fact that this disease 
typically is addressed only at the point at which 
it results in profound social consequences. 

One-quarter (25.3 percent) of referrals came 
from individuals, including concerned family 
members, friends and the self-referred; 12.1 
percent were referred by community sources 
such as social welfare organizations, religious 
organizations and mutual support programs; and 
10.6 percent were referred by addiction 
treatment providers for additional treatment. 
Very few treatment referrals came from schools 
(1.4 percent) or from employers (0.6 percent). 65 
(Figure l.C) 



Figure 1 .B 

Individuals with Select Medical Conditions 
Who Receive Treatment 




Hypertension 1 



Diabetes 2 



Major 
Depression 3 



Addiction 3 
(excluding 
Nicotine*) 



1 Ages 18 and older; Ostchega, Y., Yoon, S.S., Hughes, J. & Louis, T. 
(2008). 

2 All ages; Centers for Disease Control and Prevention. (201 1). 

3 Ages 1 2 and older; CASA Columbia analysis of The National Survey 
on Drug Use and Health (NSDUH), 201 

* Due to data limitations. 



Figure 1.C 

Sources of Referral to Publicly-Funded 
Addiction* Treatment 



Criminal Justice System 
Individuals 
Community Sources 
Addiction Treatment Providers 
Health Care Providers 
Schools 



* Excluding nicotine. 

Source: CASA Columbia analysis of The Treatment Episode 
Data Set (TEDS), 2009. 




Some respondents chose more than one response, so 
the 46.8 percent reflects those who chose either one 
of these health professionals. 



-11- 



Less than Half of Treatment Admissions 
Result in Treatment Completion 

In 2008,* less than half (42.1 percent) of 
discharges from formal addiction treatment 
services were of admissions in which treatment 
was completed. 66 The highest completion rates 
were from venues to which there were the 
fewest admissions: 

• 14.8 percent of admissions were to short- 
term residential services which had the 
highest completion rate of 54.8 percent; 

• 11.4 percent of admissions were to longer- 
term residential treatment which had a 
completion rate of 45.5 percent; and 

• 73.8 percent of admissions were to non- 
residential services which had the lowest 
completion rate of 39.1 percent. 67 

No data are available on the extent to which 
referrals were based on matching providers with 
individual treatment needs. 

Patients Face Formidable Barriers to 
Receiving Addiction Treatment 

In addition to the lack of treatment referrals 
from the health care system, many other barriers 
stand in the way of individuals accessing and 
completing addiction treatment. These include: 
a misunderstanding of the disease, negative 
public attitudes and behavior toward those with 
the disease, privacy concerns, insufficient 
insurance coverage of the costs of treatment, 
lack of information on how to get help, limited 
availability of services including a lack of 
addiction physician specialists, insufficient 
social support, conflicting time commitments, 
negative perceptions of the treatment process 
and legal barriers. Rarely is there only one 
obstacle to a person receiving needed 
treatment. 68 Although comparable national data 
for barriers to accessing smoking cessation 
treatment are not available, research indicates 
that barriers similar to those facing individuals 



Most recent available data on discharges. 



seeking treatment for addiction involving 
alcohol or other drugs stand in the way of 
smokers accessing tobacco cessation services. 69 

The Spending Gap 

In 2010, the United States spent $43.8 billion to 
treat diabetes 70 which affects 25.8 million 
people, 71 $86.6 billion to treat cancer 72 which 
affects 19.4 million people 73 and an estimated 
$107.0 billion to treat heart conditions 74 which 
affect 27.0 million people, 75 but only $28.0 
billion to treat addiction which affects 40.3 
million people. 1 76 Looking just at government 
spending, CASA Columbia calculated that in 
2005, risky substance use- and addiction-related 
spending accounted for 10.7 percent of federal, 
state and local spending, and that for every 
dollar federal and state governments spent, 95.6 
cents went to pay for the consequences of 
substance use; only 1.9 cents was spent on any 
type of prevention or treatment/ The taxpayer 
tab for government spending on the 
consequences of risky substance use and 
addiction alone totals almost $1,500 a year for 



1 There are no national data that document spending 
on treatment for addiction involving nicotine; 
although the cost estimate of $28.0 billion applies to 
the treatment of addiction involving alcohol or other 
drugs excluding nicotine, the prevalence estimate of 
those with addiction (40.3 million) includes those 
with addiction involving nicotine. 
* Due to data limitations, the prevalence estimates for 
cancer and heart conditions include individuals ages 
18 and older who have ever been told by a doctor or 
other health professional that they have the condition 
(cancer/malignancy or a heart condition). The 
prevalence estimate for diabetes includes all ages and 
the estimate for addiction includes individuals ages 
12 and older; for diabetes and addiction, the 
prevalence estimates include both diagnosed and 
undiagnosed cases. In each case, total costs of 
treatment are included without regard to age. The 
cost estimates for treating diabetes, cancer and heart 
conditions were inflated to 2010 dollars using the 
medical inflation factor (7.9 percent) found in 
SAMHSA's National Expenditures for Mental 
Health Services and Substance Abuse Treatment, 
1986-2005 publication. 

§ In addition, 0.4 cents was spent on research, 1.4 
cents on taxation or regulation and 0.7 cents on 
interdiction. 



-12- 



every person in America. Nearly one-third 
(32.3 percent) of all hospital inpatient costs are 
attributable to substance use and addiction. 78 

Most Funding for Addiction Treatment 
Comes from Public Sources 

Spending on addiction treatment totaled an 
estimated $28.0 billion in 2010. Whereas 
private payers (including private insurers and 
self-payers) are responsible for 55.6 percent 
($ 1 .4 trillion) of medical expenditures in the 
U.S., they are responsible for only 20.8 percent 
($5.8 billion) of addiction treatment spending. 79 

The concentration of spending for addiction 
treatment in public programs suggests that 
insurance across the board does not adequately 
cover costs of intervention and treatment, 
resulting in costly health and social 
consequences that stem from untreated addiction 
and that fall disproportionately to government 
programs. National data indicate that 
individuals with private insurance are three to 
six times less likely than those with public 
insurance to receive specialty addiction 
treatment. 80 

The Education, Training and 
Accountability Gap 

Compounding the profound gap between the 
need for addiction treatment and the receipt of 
such care is the enormous gulf between the 
knowledge available about addiction and its 
prevention and treatment and the education and 
training received by those who provide or should 
provide care. In spite of the evidence that 
addiction is a disease: 

• Most medical professionals who should be 
providing addiction treatment are not 
sufficiently trained to diagnose or treat it; 

• Most of those who are providing addiction 
treatment are not medical professionals and 
are not equipped with the knowledge, skills 
or credentials necessary to provide the full 
range of evidence-based services to address 
addiction effectively; 81 and 



• Addiction treatment facilities and programs 
are not adequately regulated or held 
accountable for providing treatment 
consistent with medical standards and 

82 

proven treatment practices. 

Further complicating this education, training and 
accountability gap is the fact that there are no 
national standards for the provision of addiction 
treatment and instead considerable inconsistency 
among states in the regulation of individual 
treatment providers and of the programs and 
facilities that provide addiction treatment 
services.* 

The Profound Disconnect between 
Evidence and Practice 

The prevention and reduction of risky substance 
use and the treatment of addiction, in practice, 
bear little resemblance to the significant body of 
evidence-based practices that have been 
developed and tested; indeed only a small 
fraction of individuals receive interventions or 
treatment consistent with scientific knowledge 
about what works. 83 

Providing quality care to identify and reduce 
risky substance use and diagnose, treat and 
manage addiction requires a critical shift to 
science-based interventions and treatment by 
health care professionals— both primary care 
providers and specialists. 

Significant barriers stand in the way of making 
this critical shift, including: an addiction 
treatment workforce starved of resources, 
operating outside the medical profession and 
lacking capacity to provide the full range of 
evidence-based practices including necessary 
medical care; a health professional that should 
be responsible for providing addiction screening, 
interventions, treatment and management but 
does not implement evidence-based addiction 
care practices; inadequate oversight and quality 
assurance of treatment providers and 
intervention practices; limited advances in the 



With the notable exception of the regulation of 
medication-assisted therapy for addiction involving 
opioids. 



-13- 



development of pharmaceutical treatments and 
the adoption of existing pharmaceutical 
therapies; and a lack of adequate insurance 
coverage. 

Recent efforts by government agencies and 
professional associations have begun to tackle 
these challenges to closing the evidence-practice 
gap, but are simply insufficient. 

Nothing short of a significant overhaul in current 
approaches is required to bring practice in line 
with the evidence and with the standard of care 
for other public health and medical conditions. 
Given the prevalence of risky substance use and 
addiction in America and the extensive evidence 
on how to identify and address them, continued 
failure to do so raises the question of whether 
the insufficient care that patients with addiction 
usually do receive constitutes a form of medical 
malpractice. It also signals widespread system 
failure in health care service delivery, financing, 
professional education and quality assurance. 

Recommendations and Next Steps 

It is time for health care practice to catch up 
with the science. There is no silver bullet to 
making this happen; instead, a broad set of 
comprehensive reforms must be put in place. 
Toward this end, CASA Columbia makes the 
following recommendations: 

Reform Health Care Practice 

• Incorporate screening and intervention 
for risky substance use, and diagnosis, 
treatment and disease management for 
addiction into routine medical practice. 

As essential components of routine medical 
care, all physicians and other medical 
professionals should provide their patients 
with addiction-related screening and, as 
needed: brief interventions; comprehensive 
assessment to determine disease stage, 
severity and the presence of co-occurring 
health conditions; stabilization; acute 
treatment; chronic disease management; and 
connection to support and auxiliary services. 
Patients with severe cases of addiction 



should be referred to an addiction physician 
specialist. 

• All medical schools and residency 
training programs should educate and 
train physicians to address risky 
substance use and addiction. All 

physicians should be educated and trained in 
the origins of risky substance use and 
addiction; prevention, intervention, 
treatment and management options; co- 
occurring conditions; and special population 
and specialty-care needs. These core 
clinical competencies should be required 
components of all medical school curricula, 
medical residency training programs, 
medical licensing exams, board certification 
exams and continuing medical education 
(CME) requirements, including maintenance 
of certification programs. 

• Require non-physician health 
professionals to be educated and trained 
to address risky substance use and 
addiction. Develop core clinical 
competencies in addressing risky use and 
preventing and treating addiction for each 
type of non-physician health professional 
including, physician assistants, nurses and 
nurse practitioners, dentists, pharmacists and 
graduate-level clinical mental health 
professionals (psychologists, social workers, 
counselors). Assure that these core clinical 
competencies and specialized training are 
required components of all professional 
health care program curricula, graduate 
fellowship training programs, professional 
licensing exams and continuing education 
(CE) requirements. Require all non- 
physician health professionals providing 
psychosocial addiction treatment services to 
have graduate- level clinical training in 
delivering these services. Require that all 
pharmaceutical treatments for addiction be 
provided only by a physician or in 
accordance with a treatment plan managed 
by a physician. 

• Develop improved screening and 
assessment instruments. Screening 
instruments should be adjusted or developed 



-14- 



to coincide with appropriate definitions of 
risky substance use, and assessment 
instruments should be adjusted or developed 
to mirror diagnostic criteria for addiction. 
Both screening and assessment instruments 
should address all types of addictive 
substances. 

• Establish national accreditation 
standards for all addiction treatment 
facilities and programs that reflect 
evidence-based care. As a condition of 
accreditation, accrediting organizations 
should stipulate requirements for all 
facilities and programs providing addiction 
treatment with regard to professional 
staffing (e.g., requiring them to have a full- 
time certified addiction physician specialist 
on staff to serve as medical director, oversee 
patient care and be responsible for all 
treatment services), intervention and 
treatment services (e.g., requiring them to 
provide comprehensive assessment and 
evidence-based treatment for addiction 
involving all substances that is tailored to 
the stage and severity of the disease, co- 
occurring conditions and patient 
characteristics), and quality assurance (e.g., 
requiring them to collect and report 
comprehensive quality assessment data, 
including process and outcome 
measurements). 

• Standardize language used to describe the 
full spectrum of substance use and 
addiction. Recognize addiction as a 
primary medical disease and standardize the 
language related to the spectrum of 
substance use severity in current and 
forthcoming diagnostic instruments. 
Develop a classification system based both 
on observable behavior and neurobiological 
measures that underlie different 
manifestations of addiction and related 
conditions which currently are classified and 
addressed as distinct conditions. 



Use the Leverage of Public Policy to Speed 
Reform in Health Care Practice 

• Condition grants and contracts for 
addiction services on the provision of 
quality care. Federal, state and local 
governments should require-as a condition 
of receipt of public funds-that grants, 
contracts and non-insurance reimbursement 
for addiction treatment services utilize 
evidence-based prevention and treatment 
approaches, including pharmaceutical 
therapies (provided or managed by a 
physician demonstrating the core 
competencies of addiction medicine or 
addiction psychiatry) and psychosocial 
therapies (provided by medical professionals 
or graduate-level clinical mental health 
professionals trained and licensed in the core 
competencies of addiction treatment), as 
indicated; involve other health professionals, 
individuals providing auxiliary services and 
those providing peer support, working in a 
multidisciplinary team; and generate 
positive and measurable long-term patient 
outcomes. 

• Educate non-health professionals about 
risky substance use and addiction. 

Require that the topic of risky substance use 
and addiction be included in the education 
and training of government- funded 
professionals who do not provide direct 
addiction-related services but who come into 
contact with significant numbers of 
individuals who engage in risky substance 
use or who may have addiction. These 
include, but are not limited to law 
enforcement and other criminal justice 
personnel, legal staff, child welfare and 
other social service workers and educators. 

• Identify patients at risk in government 
programs and services where costs of 
risky use and addiction are high. Federal, 
state and local governments should require 
that routine screening and brief interventions 
be provided by trained professionals in all 
educational, mental health, developmental 
disabilities, child welfare, housing, juvenile 



-15- 



justice and adult corrections services that 
receive public funding; and that patients 
who screen positive for risky use or a 
potential diagnosis of addiction be 
connected with a trained health professional 
for intervention, diagnosis, treatment and 
disease management. 

Develop tools to improve service quality. 

Federal and state governments in 
collaboration with professional associations, 
accrediting organizations and other non- 
profit organizations focusing on health care 
quality should develop and disseminate 
evidence-based tools, practice guidelines 
and performance measures oriented toward 
patient outcomes to improve the quality of 
addiction care (involving all substances) and 
require their implementation as a condition 
of continued licensure and/or accreditation. 

License addiction treatment facilities as 
health care providers. Federal, state and 
local governments should subject all 
addiction treatment facilities and programs 
to the same mandatory licensing processes 
as other health care facilities. 

Require adherence to national 
accreditation standards that reflect 
evidence-based care. As a condition of 
licensure, federal, state and local 
governments should stipulate that all 
facilities and programs providing addiction 
treatment adhere to established national 
minimum standards for accreditation. 

Require that all insurers provide 
coverage for comprehensive addiction 
care. Require that all health insurers- 
public and private— provide coverage for all 
insured individuals for patient education, 
screening and intervention for risky 
substance use and treatment and 
management of addiction (involving all 
substances associated with addiction) 
consistent with standards of medical 
practice, eliminating exemptions. As a 
condition of reimbursement, public payers 
and private insurance companies should be 



mandated to require that all addiction 
interventions and treatment be directly 
provided, supervised or managed by trained 
medical professionals. Public payers and 
private health insurance companies should 
encourage participating providers and 
facilities to adopt evidence-based practices, 
institute quality-improvement measures and 
assess patient outcomes. To help ensure 
comprehensive coverage and appropriate 
medical care, the Uniform Accident and 
Sickness Policy Provision Law (UPPL), 
which bars insurance coverage for injuries 
sustained by a person who was under the 
influence of alcohol or other drugs at the 
time of the injury, should be eliminated. 

• Expand the addiction medicine 

workforce. Accelerate the work begun by 
the American Board of Addiction Medicine 
Foundation to develop residency training 
programs in addiction medicine and secure 
residency accreditation from the 
Accreditation Council for Graduate Medical 
Education (ACGME). Pursue and gain 
recognition of addiction medicine by the 
American Board of Medical Specialties 
(ABMS). Support the efforts of ACGME- 
accredited addiction psychiatry residencies 
to increase the number of enrolled residents. 
Through these actions, assure that addiction 
medicine training programs are available to 
physicians, that training opportunities within 
addiction psychiatry are expanded, and that 
such specialty care is formally recognized 
and available in every hospital throughout 
the country and through every health care 
system. 

• Implement a national public health 
campaign. Implement a nationwide public 
health campaign through federal agencies 
charged with protecting the public health to 
educate the public about all forms of risky 
substance use and addiction. 

• Invest in research and data collection. 

Invest in research designed to improve and 
track progress in addiction prevention, 
treatment and disease management and to 
find a cure for addiction. 



-16- 



Implement the National Institutes of 
Health's (NIH) recommendation to create 
a single institute addressing substance use 
and addiction. Create a unified national 
institute focused on substance use and 
addiction, recognizing the overarching 
disease of addiction rather than continuing 
the focus on different manifestations of the 
disease-tobacco, alcohol, other drug use— 
and including the risky use of all addictive 
substances. Include in the research portfolio 
addiction involving behaviors other than 
substance use, and focus on the causes, 
correlates, consequences, interventions, 
policies and possible cures for all 
manifestations of the disease. The portfolio 
of the institute also should include health 
conditions resulting from risky use and 
addiction and other conditions which 
increase the risk of developing addiction. 



-18- 



Chapter II 

What Is Addiction? 

Addiction* is a complex brain disease with 
significant behavioral characteristics. 1 In many 
but not all cases, it involves the use of nicotine, 
alcohol and other drugs. ' Addiction involving 
these substances typically originates with use in 
adolescence when the brain is still developing 
and is more vulnerable to their effects. 2 If 
untreated, it can become a chronic and relapsing 
condition, requiring ongoing professional 
treatment and management. 3 

Although there has been an evolution in 
scientific understanding of the disease, public 
attitudes and health care practice have not kept 
pace with the science. Terms used to describe 
different levels of substance use and addiction's 
many forms lack precision, obscuring important 
differences in the use of addictive substances 
and the nature and severity of the illness and 
complicating our ability to treat it effectively. 



In this report, we have used the general term 
addiction to apply to those who meet criteria for past- 
month nicotine dependence based on the Nicotine 
Dependence Syndrome Scale (NDSS) and those who 
meet diagnostic criteria for past year alcohol and/or 
other drug abuse or dependence (excluding nicotine) 
in accordance with the Diagnostic and Statistical 
Manual of Mental Disorders (DSM-IV). (The DSM 
refers to substance abuse and substance dependence 
as substance use disorders. The criteria for nicotine 
dependence in the NDSS parallel those of the DSM- 
IV.) This definition is consistent with the current 
move to combine abuse and dependence into an 
overarching diagnosis of addiction in the upcoming 
DSM-V. 

1 Other drugs include federally controlled illicit drugs 
and the misuse of controlled prescription drugs. The 
term addiction also has been used in reference to 
compulsive behaviors involving eating, gambling and 
other activities that affect the brain's reward system 
and which may develop independent of or in 
combination with other manifestations of addiction. 
This report, however, focuses only on addiction 
involving nicotine, alcohol and other drugs. 



-19- 



Addiction Is a Brain Disease 

Advances in neuroscientific research, including 
animal studies and brain imaging, demonstrate 
clearly that addiction is a primary and often 
chronic disease of the brain.* 4 The risk factors 
for developing the disease include a genetic 
predisposition and a range of biological, 
psychological and environmental influences. 5 
There is a growing body of evidence showing 
the brain circuits that are implicated in substance 
addiction in general also are involved in other 
compulsive or addictive behaviors such as those 
related to gambling, certain forms of disordered 
eating (e.g., bulimia, obesity) and compulsive 
sexual activity. For these reasons, researchers 
are beginning to explore whether substance 
addiction might be part of a syndrome 
characterized by: 

• Shared neurobiological and psychosocial 
antecedents (risk factors); 

• Production of desirable effects upon 
involvement with the rewarding object or 
activity; 

• Shared manifestations and outcomes (e.g., 
biological ones such as tolerance or 
withdrawal or behavioral or psychological 
ones such as deceit, shame, guilt or 
depression); and 

• A shared course of the disease (e.g., 
improvement, relapse, remission and the 
potential for progression to disability or 
death). 7 



A primary disease indicates that it is not simply a 
symptom or effect of another disease or condition. 



The focus of this report is on addiction involving 
nicotine, alcohol and other drugs. Use of these 
substances can result from an existing brain 
dysfunction; use also can alter the structure and 
function of the brain, dramatically affecting 
judgment and behavior. 8 The amount and 
duration of substance use that results in brain 
changes and addiction depends on the individual 
and the particular substances used. f 9 

As yet, there is no conclusive biological marker 
of addiction; therefore the diagnosis of addiction 
is based on its symptoms including the 
compulsive use of addictive substances, 
significantly impaired function and persistent 
use despite negative consequences. 1 10 These 
symptoms that characterize addiction are 
cognitive and behavioral manifestations of the 
underlying disease and its effects on the brain. 1 1 
The foundations of the disease may exist in 
certain individuals even before they ever use an 
addictive substance and, in some cases, once the 
disease develops it persists even when an 
individual is not actively engaged in substance 



1 The addictive potential of a substance is 
determined not only by its intrinsic ability to 
stimulate the reward circuits of the brain, but also by 
the speed with which it crosses the blood-brain 
barrier (i.e., how soon after initial 
ingestion/injection/inhalation it reaches receptors in 
reward circuits of the brain). 
* Other physical signs such as intoxication, 
withdrawal, needle-related findings, co-infections, 
and laboratory findings— such as abnormalities in 
liver function tests or positive breath or urine tests- 
can aid in the diagnosis. 



...addiction is not about drugs, it's about 
brains. It is not the substances a person uses 
that make them an addict; it is not even the 
quantity or frequency of use. Addiction is about 
what happens in a person 's brain when they are 
exposed to rewarding substances or rewarding 
behaviors, and it is more about reward circuitry 
in the brain and related brain structures than it 
is about the external chemicals or behavior that 
"turn on " that reward circuitry. 14 



Unfortunately, keeping the emphasis on just the 
behavioral manifestations presumes that the 
problem is present when the behavior is present 
and the problem is resolved if the behavior is not 
present for whatever duration of time, even 
though the underlying disease process may be 
present and even progressing, or contributing to 
other manifestations, signs and symptoms that 
may be overlooked. 13 



-20- 



The areas of the brain affected by this complex 
disease are among those that are responsible for 
survival-including the areas associated with 
motivation, decision making, risk and reward 
assessment, pleasure seeking, impulse control/ 
inhibition, emotion, learning, memory and stress 
control. 15 

In order to reinforce activities necessary for 
survival, the brain produces feelings of pleasure 
in response to the satisfaction of fundamental 
drives such as hunger, thirst and sex. 16 
Behaviors that lead to these rewards tend to be 
reinforced and thus perpetuated over time. 17 On 
a neurological level, this reinforcement is a 
process carried out by chemical messengers that 
flood the reward circuits of the brain. 18 
Virtually all addictive substances affect the 
pleasure and reward circuitry deep in the brain* 
which is activated by the neurotransmitter 
dopamine.' 19 



* The mesolimbic reward system. 
' The neurotransmitter serotonin also is involved in 
some forms of substance addiction; it plays a role in 
motivated or directed actions such as attaining 
addictive substances and also influences dopamine 
levels in the brain. Hallucinogenic drugs like LSD 
and Ecstasy target serotonin systems in the brain. 



Addictive substances drive behavior by causing 
the release of more dopamine within brain 
reward circuits than almost all natural rewards 
including those tied to food and sex. 20 With 
repeated use of addictive substances, the brain 
begins to expect this stimulation and an addicted 
individual may experience intense desire or 
cravings whenever the addictive substances are 
not readily available and especially when the 
individual is exposed to cues associated with 
substance use. 21 Recent research points to 
evidence that use of one addictive substance can 
increase the risk of use of and addiction 
involving another substance; for example, 
nicotine use can prime the brain, making it more 
susceptible to developing addiction involving 
cocaine.* 22 Signals in the environment such as 
seeing a drug-using friend or passing a bar, or 
emotional signals such as feeling stressed or sad 
also become associated with the addictive 
substance and spur the drive to obtain it. 23 

As use continues, the pleasure associated with 
the dopamine release that results from the 
ingestion of an addictive substance— or from its 
anticipation-can become consuming to the point 
where fundamental natural drives and associated 
behaviors lose their value in comparison. 25 

At the same time, the brains of substance-using 
individuals may adapt to the unnaturally high 
levels of dopamine that result from continued 
substance use and may respond by reducing the 
normal release of dopamine as well as the 
number of dopamine receptors in the brain. 26 
When this happens, the addictive substance may 
become necessary just for the person to feel 
normal. 27 Compared to non-substance users, the 
brains of chronic substance users appear to have 
lower baseline levels of dopamine, making it 
difficult for them to achieve feelings of pleasure 
from substance use and other behaviors that 
once were pleasurable. 28 

Changes in the function and structure of the 
brain result in specific, compulsive behaviors 
aimed at obtaining and using addictive 
substances. 29 The cognitive control of an 



1 This study provides a biological mechanism for the 
"gateway effect." 



Definition of Addiction 
American Society of Addiction Medicine 

Addiction is a primary, chronic disease of brain 
reward, motivation, memory and related circuitry. 
Dysfunction in these circuits leads to 
characteristic biological, psychological, social and 
spiritual manifestations. This is reflected in an 
individual pathologically pursuing reward and/or 
relief by substance use and other behaviors. 

Addiction is characterized by inability to 
consistently abstain, impairment in behavioral 
control, craving, diminished recognition of 
significant problems with one's behaviors and 
interpersonal relationships and a dysfunctional 
emotional response. Like other chronic diseases, 
addiction often involves cycles of relapse and 
remission. Without treatment or engagement in 
recovery activities, addiction is progressive and 
can result in disability or premature death. 24 



-21- 



addicted individual is so weakened that even 
when he or she wants to cut down or stop using 
an addictive substance, it becomes extremely 
difficult to do so. 30 



People may choose to take drugs, but no one 
chooses to be an addict. 

-Participant 
CASA Columbia Focus Group 
May 2008, Philadelphia, PA 



The Risk Factors for Addiction 

Genetic factors play a major role in the 
development of addiction as do individual 
biological and psychological characteristics and 
environmental conditions. 31 These factors affect 
both the initial use of an addictive substance and 
the progression from initiation of substance use 
to regular use to addictive use. 32 

Whereas biological, psychological and 
environmental factors— such as impairments in 
the brain's reward circuitry, compensation for 
trauma and mental health problems, easy access 
to addictive substances, substance use in the 
family or media and peer influences-play a 
large role in whether an individual starts to 
smoke, drink or use other drugs, 33 genetic 
factors are more influential in determining who 
progresses to risky use or addiction. 34 A factor 
that is particularly predictive of risk, however, is 
the age of first use; almost all cases of addiction 
begin with substance use before the age of 2 1 , 
when the brain is still developing. 35 



development of addiction. Although certain 
specific genetic factors predispose an individual 
to addiction involving a particular substance, 37 
genetic factors also appear to contribute 
generally to the risk of use and addiction. 38 
Advances in genetic research have enabled 
scientists to identify individual genes, including 
genetic variations in components of the 
dopamine transmission system, 39 implicated 
both in the likelihood of substance use and of 
addiction involving a variety of substances. 40 

Genetic variations may affect a person's ability 
to metabolize an addictive substance 41 or to 
tolerate it. 42 Studies have found that genetics 
account for between half and three quarters of 
the risk for addiction. ' 43 Genetic factors appear 
to be stronger drivers than environmental factors 
of initiation of substance use at an early age. 44 

Nicotine. Adolescents who do not have a 
certain variant of the gene that is responsible for 
the enzyme that metabolizes nicotine* progress 
from smoking to addiction involving nicotine 
faster than adolescents with that type of gene. 45 
Other genetic variations in genes that determine 
how nicotine receptors in the brain function 5 
also are linked to increased risk of addiction 
involving nicotine and difficulty quitting 
smoking. 46 

Alcohol. Individuals whose genetic makeup 
influences them to have a higher tolerance for 
alcohol are at increased risk of developing 



Genetic Risks 



Twin and adoption studies confirm a genetic 
role in the likelihood of substance use and the 



These studies help distinguish the roles of genetics 
and environment in the development of addiction. 
Studies of adopted children allow researchers to 
compare the adopted child both to her biological 
parents with whom she shares genetic features but no 
environmental experiences and to her adopted parents 
with whom she shares environmental experiences but 
no genetic features. Studies of identical and fraternal 
twins allow researchers to isolate genetic similarities 



from environmental similarities. Identical twins are 
genetically identical and fraternal twins share an 
average of 50 percent of their genes, but both types of 
twins typically experience a shared environment if 
reared together. 

f The majority of the genetics literature focuses on 

addiction involving alcohol; the estimated extent of 

genetic influence on addiction involving other drugs 

varies by the type of drug. 

* CYP2A6. 

§ e.g., CHRNA5. 



-22- 



addiction. Adopted children with biological 
parents who have addiction involving alcohol 
are at least twice as likely as are adopted 
children without such parents to develop 
addiction involving alcohol. 48 Individuals 
whose genetic makeup produces involuntary 
skin flushing and other unpleasant reactions to 
alcohol are at reduced risk of developing 
addiction involving alcohol. 49 



Other Drugs. Genetic influences have been 
implicated in marijuana use 51 and particular 
genes have been associated with marijuana 
cravings and withdrawal symptoms. 52 Twin 
studies have found genetic risks for 
hallucinogen, opioid, sedative and stimulant use 
and addiction. 53 

Biological Risks 

In addition to genetic variations, certain 
individuals have neurological, structural or 
functional differences that make them more 
susceptible to addictive substances. 54 This is in 
part due to individual differences in how the 
brain produces and reacts to dopamine. 55 Some 
research indicates that individuals with a 
naturally low level of dopamine response to 
addictive substances are at increased risk of 
engaging in substance use in order to achieve a 
greater experience of reward. Other research 
suggests that individuals with a biological 



There is some indication that these individuals have 
less cognitive impairment following the ingestion of 
alcohol and, therefore, may not perceive the negative 
experiential aspects of alcohol use in the same 
manner as individuals whose brains are more strongly 
affected by alcohol ingestion. 



tendency toward heightened dopamine response 
also are at increased risk because of their 
enhanced or above average experience of reward 
or pleasure from engaging in substance use. 56 
Other biological risks may involve damage or 
deficits in the regions of the brain' responsible 
for decision making and impulse control. 57 

Psychological Risks 

Clinical mental health disorders such as 
depression and anxiety and psychotic disorders 
such as schizophrenia, as well as behavioral 
disorders such as conduct disorder and attention- 
deficit/hyperactivity disorder 58 — and sub-clinical 
symptoms of these conditions 59 ~are strongly 
linked to substance use and addiction and to the 
risk of transitioning from substance use to 
addiction. 60 Individuals whose brain 
development has been altered by stress are more 
sensitive to the effects of addictive substances 
and more vulnerable to the development of 
addiction. 61 Likewise, individuals with post- 
traumatic stress disorder (PTSD), common 
among veterans and individuals in active 
military duty, are at increased risk of developing 
addiction. 62 People who have risk-taking or 
impulsive personality traits 63 or who have low 
self-esteem 64 also are likelier to engage in 
substance use 65 as are victims of trauma or 
abuse. 66 Expectations play a role in substance 
use as well, since people who expect that using 
addictive substances will be a positive and 
rewarding experience—in terms of physical 
effects, mood or behavior— are likelier to smoke, 
drink alcohol or use other drugs than are those 
with more balanced or negative expectations. 67 

Environmental Risks 

Many factors within an individual's family, 
social circle and community, as well as the 
larger cultural climate, increase the likelihood 
that an individual will use addictive substances 
and develop addiction. 



' e.g., in the orbitofrontal cortex and anterior 
cingulate cortex. 



It's theoretically possible to take kids before 
they first drink, find out whether they have any 
gene variations, and say to them, 'If you choose 
to be a drinker, then be careful because it's very 
likely that you '11 need to drink more to have the 
same effect. ' 50 

-Marc A. Schuckit, MD 
Distinguished Professor of Psychiatry 
Department of Psychiatry 
University of California, San Diego 



-23- 



People who grow up in homes in which parents 
routinely expose their children to smoking, 
excessive drinking or other drug use are at 
increased risk of substance use, as are those 
whose parents do not convey strong anti- 
substance use messages and expectations. 68 The 
nature of the parent-child relationship is key; 
people who come from families with high levels 
of parent-child conflict, poor communication, 
weak family bonds and other indicators of an 
unhealthy parent-child relationship are at 
increased risk of substance use and addiction. 69 
Individuals whose peers engage in substance use 
or convey approval of such use are at increased 
risk as well. 70 

The simple fact of availability of addictive 
substances makes it likelier that an individual 
will use them. 72 Homes where liquor and 
medicine cabinets are open to teens increase the 
chances that teens will use these substances. 73 
People who live in communities where addictive 
substances are readily available, where using 
such substances is considered normal or 
expected or where tobacco and alcohol retail 
outlets are prevalent are at increased risk. 74 
Widespread access to controlled prescription 
drugs contributes to the misuse of these 
substances 75 and increased access to marijuana 
marketed as medicine is linked to increased 
use. 76 Community tolerance of high levels of 
substance use or of experimenting with and 
using addictive substances as a normal rite of 
passage for adolescents also increases the risk of 
use, as does lax enforcement of governmental 
policies and regulations restricting use. 77 

Exposure to advertising and marketing messages 
that promote or glamorize smoking and drinking 
increases the chances that these substances will 
be used and misused. 78 Direct-to-consumer 
marketing of controlled prescription drugs may 
encourage substance use by conveying the 
message that there is a pill for every ill. 79 

Environmental influences can exacerbate 
existing genetic, biological and psychological 
risks for substance use, further increasing the 
chances that an individual will engage in risky 
substance use, sometimes to the point of 
addiction. 80 



Early Initiation of Use 

Adolescence is the critical period of 
vulnerability for the onset of substance use and 
the development of addiction. 81 In 96.5 percent 
of cases, addiction originates with substance use 
before the age of 21. 82 Because the parts of the 
brain responsible for judgment, decision- 
making, emotion and impulse control are not 
fully developed until early adulthood, 
adolescents are more likely than adults to take 
risks, including experimenting with addictive 
substances. 83 At the same time, because these 
regions of the brain are still developing, they are 
more vulnerable to the negative impact of 
addictive substances, further impairing 
judgment, interfering with brain development 
and increasing the risk of addiction.* 84 The 
combination of early initiation of use and 
genetic, biological, psychological or 
environmental risk factors dramatically hike the 
chances that addiction will develop. 85 
Adolescents with a genetic predisposition to 
addiction and/or co-occurring mental health 
problems are at the greatest risk of progressing 
from substance use to addiction. 86 



... [addiction] is not simply a disease of the 
brain, but it is a developmental disorder, and it 

71 

begins early in life— during adolescence. 

-Nora D. Volkow, MD 
Director 

National Institute on Drug Abuse (NIDA) 



Risky Use and Addiction 
Frequently Co-occur with Other 
Health Conditions 

Individuals with addiction are likely to have co- 
occurring health conditions. 87 Smoking causes 
bladder, esophageal, laryngeal, lung and oral 
cancer. 88 From 2000-2004, the top three causes 
of smoking-attributable death were lung cancer, 



As is true of much of health research, the research 
on the neurological effects of addictive substances on 
the adolescent brain primarily has been conducted on 
animals. 



-24- 



ischemic heart disease and chronic obstructive 
pulmonary disease. 89 Alcohol consumption 
contributes to diseases that are among the top 
causes of death, including heart disease, cancer 
and stroke. 90 Addiction involving alcohol is 
linked to cirrhosis, alcoholic hepatitis, chronic 
pancreatitis, cardiomyopathy, heart arrhythmias, 
stroke and neoplasms of the liver, pancreas and 
esophagus. 91 Heavy alcohol use and addiction 
involving alcohol are associated with the 
incidence and re-infection of tuberculosis. 92 
Injection drug use is a risk factor for infectious 
diseases, including HIV, hepatitis C and 
hepatitis B. 93 The incidence of various forms of 
cancer, 94 heart disease 95 and sexually-transmitted 
diseases 96 are higher among those with addiction 
than among those without addiction. 

Risky use and addiction also have high rates of 
co-occurrence with many mental health 
problems including depression, anxiety, post- 
traumatic stress disorder, bipolar disorder, 
schizophrenia and other neuropsychiatric 
disorders such as attention deficit/hyperactivity 
disorder, conduct disorder and eating 
disorders. 98 The association between addiction 
and co-occurring health conditions can result 
from several factors. Substance use may 
precipitate the onset of other conditions such as 
depression or anxiety disorders. 99 Other times, 
the health conditions may precede the onset of 
addiction, as often occurs with mood disorders 
and attention deficit/hyperactivity disorder, 100 as 
individuals attempt to self-medicate the pain or 
distress associated with their illness. 101 The two 
types of conditions also may co-occur as a 
function of an underlying psychological or 
biological propensity, or substance use can 
exacerbate or complicate symptoms of existing 
health conditions. 102 



the risk of relapse. In these cases, addiction is a 
chronic disease-like heart disease, hypertension, 
diabetes and asthma— defined as having a clear 
biological basis, a behavioral component, 
environmental influences, unique and 
identifiable signs and symptoms, a predictable 
course and outcome and the need for continued 
management following treatment. 104 

Like any other chronic condition, addiction 
rarely abates after a single course of medication 
or other treatment or after a single attempt to 
alter one's lifestyle or behavior. As is true of 
other chronic conditions, individuals with 
addiction can have symptom-free periods and 
periods of relapse. 105 Many patients relapse 
multiple times and still others never achieve 
effective disease management. 106 In fact, 
addiction frequently is characterized as a disease 
where relapse is virtually inevitable. Yet, this 
conception of addiction might be due to the 
focus of research studies on those with the most 
severe manifestations of addiction, who 
experience multiple episodes of symptom 
relapse and co-existing health and social 
problems over the course of many years or even 
a lifetime. 107 Furthermore, very few people with 
addiction actually receive adequate, effective, 
evidence-based treatment. 108 The seemingly 
high rates of relapse* may be due, at least in 
part, to inadequate or ineffective interventions 
and treatments. 109 



It's not surprising to us now that when you stop 
the treatment, people relapse. It doesn 't mean 
that the treatment doesn 't work, it just means 
that you need to continue treatment. 91 

-Daniel Alford, MD, MPH 
Associate Professor of Medicine 
Boston University School of Medicine 



Addiction Can Be a Chronic 
Disease 

Once an individual develops addiction, changes 
in the brain's reward circuitry may remain even 
after cessation of substance use. 103 These 

changes leave addicted individuals vulnerable to 

physiological and environmental cues that they * Relapse rates for those with addiction are 

have associated with substance use, increasing comparable to relapse rates for those with other 

chronic diseases. 



-25- 



Models for Understanding 
Addiction 

The model for how we understand addiction is 
critical because it influences how individuals 
with addiction are treated in society and guides 
the nature of the services provided to address the 
disease. 110 The current model of addiction 
recognizes that it is a complex brain disease 111 
and that multiple determinants and systems 
influence substance use and its progression to 
addiction. 112 Although this model is based on a 
large and growing body of scientific evidence, 
treatment practice and public attitudes still 
reflect earlier models of understanding the 
condition. 

Since the 1700s, with few exceptions, 113 two 
different models have dominated society's views 
on addiction, driven in large part by 
sociopolitical influences and also by developing 
knowledge about the science of addiction. 1 14 

The moral model of addiction framed addiction 
primarily as a failure of personal responsibility 
or morality. It asserted that addiction could be 
addressed simply by requiring personal 
responsibility and accountability on the part of 
the person who is addicted. This approach has 
contributed to: 

• The stigma associated with addiction, 
attaching blame to the individual, creating 
shame and embarrassment, increasing the 
likelihood of discrimination and decreasing 
the chances that the addicted individual will 
seek or receive effective treatment. 115 

• Restrictions in benefits for addicted 
individuals. In 1995, a Congressional vote 
discontinued Supplemental Security Income 
(SSI) disability benefits to individuals 
whose primary diagnosis was addiction 
involving alcohol or other drugs. 116 And, 
the majority of states in the U.S. currently 
are proposing or adopting legislation that 
condition the receipt of public services 
including welfare, unemployment 
assistance, job training, food stamps and 
public housing on passing a drug test. 117 



The disease model of addiction, in contrast to the 
moral model, acknowledged biology and 
genetics as significant contributors to addiction, 
drawing on advances in genetics and brain 
research. 1 This approach has contributed to the 
concern that viewing addiction as a disease 
might: 

• Release the individual from personal 
responsibility and the need for self- 
control, 119 and 

• Engender feelings of hopelessness with 
regard to effective treatment and the 
possibility of recovery. 120 

These concerns, however, rarely are raised in 
relation to other health problems and appear, at 
least in part, to be reflective of the moral model 
of addiction. 

Evolving Approaches to Addressing 
Addiction 

America's approach to addressing substance use 
and addiction has been filled with contradiction. 
For example, at the turn of the 20 th century, 
cigarette smoking was frowned upon. 121 Thanks 
to effective marketing by the tobacco industry, 
that view was replaced by one of tobacco use as 
glamorous and even healthful, 122 only to be 
supplanted in the mid- 1 960s by a growing 
understanding that cigarette smoking is a 
significant contributor to poor health and 
disease. 123 

Physicians prescribed marijuana and cocaine for 
a variety of ailments in the late part of the 1 9 th 
century only to scale back in the first decades of 
the 20 th century in response to increasing 
recognition of the adverse effects of these drugs 
and increasing regulatory restrictions on their 
use; today, there is a return to attempting to 
frame marijuana as medicine. 124 Similarly, 
opium was used in the early part of the last 
century to treat diarrhea, dysentery and 
coughs. 125 In response to the proliferation of 
marijuana, hallucinogen, cocaine and heroin use 
in the late 1960s and early 1970s-and their 
association with political protest, crime and 



-26- 



addiction— and to the emerging "crack epidemic" 
in the late 1980s, substance use and addiction 
increasingly were criminalized. 126 This trend 
toward criminalization was reflected in federal 
and state laws such as New York's Rockefeller 
Drug Laws which created mandatory minimum 
sentences of 15 years to life for possession of 
four ounces of narcotics (about the same as a 
sentence for second-degree murder). 127 Later, 
prescription opioid medications were heavily 
marketed for pain which led to increased 
negative consequences associated with their use 
and renewed calls for increased legal 
restrictions. 128 (See Text Box on page 28.) 

The latter half of the 20 th century has seen more 
systematic and consistent progress in how 
addiction is perceived in the medical field. In 
1956, the American Medical Association 
(AMA) declared that alcoholism is an illness and 
that it can and should be treated within the 
medical profession; 130 in 1967, the AMA 
elaborated on this position in a manual for 
physicians declaring that alcoholism is 
characterized by a distinct pattern of symptoms, 
chronicity, progression, and by a tendency 
toward relapse and that it should be treated by 
physicians. 131 The U.S. Comprehensive Alcohol 
Abuse and Alcoholism Prevention, Treatment, 
and Rehabilitation Act of 1970 recognized 
alcoholism as "an illness requiring treatment and 
rehabilitation." 132 



Alcoholism must be regarded as within the 
purview of medical practice. The Council on 
Mental Health, its Committee on Alcoholism, and 
the profession in general recognizes this syndrome 
of alcoholism as illness which justifiably should 
have the attention of 'physicians. , 133 

—American Medical Association 
Reports of Officers 
Report of the Board of Trustees, 1956 



In 1979, the AMA Council on Scientific Affairs 
published Guidelines for Physician Involvement 
in the Care of Substance-Abusing Patients 
which put the weight of policy behind the 
declaration that physicians are responsible for 
addressing alcohol and other drug use in their 



patients by engaging in diagnosis and referral (at 
a minimum) and preferably interventions that 
would ready the patient for treatment or actually 
providing treatment and follow-up care; the 
guidelines also specify the actions and 
knowledge required for each level of physician 
involvement. 134 In 1989, a third of a century 
after declaring that alcoholism is a disease, the 
AMA adopted a policy declaring addiction 
involving other drugs-including nicotine-to be 
a disease. 135 

Addiction involving alcohol and other drugs first 
was viewed by the field of psychiatry as a 
symptom of an underlying personality disorder 
in 1952; 136 in 1980, addiction involving nicotine, 
alcohol and other drugs was described by the 
American Psychiatric Association (APA) f as an 
independent disorder-a substance use disorder 
for which the clinician was instructed to specify 
the substance involved in the addiction. 137 

From the mid- 1 990s through the present day 
there has been a growing backlash against a 
punitive approach to individuals with 
addiction, 138 concomitant with the growth in 
scientific understanding of the brain processes 
underlying addiction and the development of 
evidence-based pharmaceutical and psychosocial 
therapies to treat it. 139 Yet it was not until the 
late 1 990s that addiction began to gain broader 
recognition as a brain disease. 140 



The history of addiction as a brain disease looks 
a lot like the history of atoms or germs, insofar 
as these were all older and controversial ideas 
for which scientific confirmation later became 
available.™ 

-David T. Courtwright, PhD 
Professor, Department of History 
University of North Florida 



By the American Psychiatric Association's 
Diagnostic and Statistical Manual of Mental Disorder 
(DSM), first edition. (See page 31 for a description 
oftheDSM.) 
1 In the DSM-III. 



-27- 



Select Examples of Shifting Perceptions 
of Harms and Benefits of Addictive Substances in the U.S. 

Tobacco. Cigarette smoking generally was frowned upon at the turn of the 20 th century. 141 However, highly 
effective marketing campaigns conducted during the early and mid-20 th century by the major tobacco companies 
tremendously enhanced the appeal of smoking for men and women alike. The image of the cigarette smoker 
projected by such campaigns— and by the entertainment media— was that of glamour, sophistication and even fitness. 
Some medical professionals even signed on to the health message; tobacco advertisements featured physicians and 
some appeared in medical journals. 142 In 1950, a landmark study linking smoking to lung cancer was published in 
the prestigious Journal of the American Medical Association. 143 Over the next decade, more than 7,000 articles were 
published linking smoking with lung cancer and other life -threatening diseases. 1 In 1964, the first U.S. Surgeon 
General's Report on Smoking and Health was published, concluding that smoking was hazardous to health and that 
immediate action was warranted. 145 It spurred a major, highly successful public health effort to reduce smoking and 
other tobacco use. The truth about the dangers of smoking and the health consequences of second-hand smoke, 
finally reached the public through unmistakable health evidence and powerful anti-tobacco health and legal 
campaigns. Perceptions of smoking (and smokers) largely turned negative, public policy shifted toward widespread 
bans and restrictions on smoking, and smoking rates have declined significantly. 

Alcohol. The duality of alcohol— as a staple for celebrations, religious rituals or relaxing with family and friends, and 
on the other hand as an underlying driver of crime, poverty, family dysfunction and illness-has a very long history. 
Alcohol was considered in early America to be helpful for curing ailments, natural and healthy when used in 
moderation, as an important source of nutrients and as a healthier alternative to water which often was 
contaminated. 146 The 19 th and early 20 th centuries saw a change in attitudes wherein excessive alcohol use was seen 
as an impediment to worker productivity and as a contributing factor to problems such as domestic violence, poverty 
and crime. 147 The initial push for moderation in alcohol use (temperance) soon became a push for prohibition. 148 
Once the futility of prohibition became apparent and the law ultimately repealed, alcohol has been both extolled 
through ubiquitous marketing and condemned for its tremendous societal and health-related costs. Conflicting views 
on the dangers versus benefits of alcohol use persist with a growing list of scientific findings that the health and 
social risks of excessive alcohol use and dangers of underage drinking outweigh any ostensible health benefits of 
non-excessive drinking. 

Marijuana. In colonial America, marijuana was a major commercial crop alongside tobacco and was grown for its 
fiber much like cotton. In the 1920s, the recreational use of marijuana began to catch on, particularly among 
entertainers. Marijuana use at this time was not illegal and was not considered a social threat. Between the mid- 19th 
and 20th centuries, marijuana was even prescribed for various medical conditions including labor pains, nausea and 
rheumatism. In the 1950s, marijuana use became increasingly popular and, in the 1960s, it became a symbol of 
rebellion against authority. In the Controlled Substances Act of 1970, the federal government classified marijuana 
along with heroin and LSD as a Schedule I drug-having the highest abuse potential and no accepted medical use- 
formalizing its illegality and highlighting its potential for addiction. The 1980s and early 1990s saw the passage of 
strict laws and mandatory sentences for possession of marijuana as well as the development of stronger strains of the 
drug. 149 In recent years, a growing number of states have enacted laws bypassing the established process of bringing 
drugs to market in the U.S. which assures safety and efficacy and permitting the use of marijuana as "medicine." 150 

Opioids. The prescribing and dispensing of opioids by physicians and pharmacists were the major causes of the 
increase in narcotic use (and addiction) that occurred in the 19 th century. 151 Opium and morphine were believed to 
cure a variety of health conditions. 152 At the turn of the 20 th century, the Bayer Pharmaceutical Company promoted 
heroin as "the sedative for coughs." 153 At this time, there was some concern about the "moral degradation" caused by 
opioid use, but drug users were not subject to legal sanctions. 154 Increased concern about the spread of opioid 
addiction prompted the passage of several Acts restricting the use and distribution of narcotics and making their non- 
medical use illegal. 155 Since that time, perceptions of narcotic/opioid use diverged dramatically, with prescription 
opioids marketed as beneficial and illegal opioids seen as a scourge. In the late 1990s, the growth in the use of 
prescribed pain relievers, tranquilizers and stimulants resulted in a widespread epidemic of prescription drug misuse 
and addiction among people of all ages, which now pose an even larger addiction problem than their illegal 
counterparts. 156 In response, efforts to control this misuse have led, in some cases, to the under-treatment of pain. 157 



-28- 



Defining the Terms 

Part of the problem in understanding the nature 
of addiction is the lack of precision and 
uniformity in the terms used to describe it and 
distinguish it from substance use that threatens 
health and safety but is not addiction. 158 Various 
terms such as experimentation, use, misuse, 
risky use, hazardous use, excessive use, abuse, 
dependence and addiction can be found in the 
research literature and in popular parlance. 
There are no standard connotations in use with 
regard to the severity of the behavior, the 
consequences of the behavior or the ability of 
the individual to stop the behavior. Nor is there 
recognition that the severity and consequences 
of different levels of use vary considerably by 
substance and with the age, gender and health 
status of the user. 

Further confusion can be found in the misuse of 
the word "treatment" which historically has been 
used to refer to a host of interventions including 
detoxification, clinical treatment and 
professionally-administered disease 
management, social and mutual support and 
other auxiliary services.* 159 Rarely has the term 
treatment been reserved for those interventions 
that are based in the clinical and scientific 
evidence, as it is for the treatment of other 
diseases. 

As with other diseases, precise definitions are 
essential to be able to stage the disease and 
develop effective interventions and treatments. 

The Continuum of Substance Use 

Substance use includes smoking or otherwise 
ingesting tobacco products, drinking alcohol or 



Detoxification services are not considered 
components of addiction treatment; rather, they are 
precursors to treatment designed to manage acute 
states of intoxication or withdrawal. Social and 
mutual support and other auxiliary services can be 
critical in supporting a patient through treatment and 
helping over the long term to sustain advances 
achieved through clinical treatment and to avoid 
relapse. 



using other addictive substances. The health 
consequences of use of these substances increase 
with frequency and quantity of use. 160 The 
continuum of use ranges from no use on one 
end, to use that does not involve negative 
consequences, to risky use-a public health 
problem, to addiction-a medical problem. 

Risky Substance Use: A Public Health 
Problem. Risky substance use is defined, for 
the purposes of this report, as the use of tobacco, 
alcohol or other drugs in a way that can increase 
the probability of harm to the user or to others 
but does not meet clinical criteria for addiction* 
More specifically, it includes the following 
(sometimes-overlapping) categories: 

• Use of any addictive substance by people 
under the age of 21, for whom there is no 
known safe level of use. § 



1 Regardless of the legal status of the substance. 
* The term risky use was chosen to reflect a range of 
health and social risks inherent in the use of these 
substances and to underscore the fact that significant 
hazards can result from such use even in the absence 
of clinical addiction. See Chapter III for a complete 
account of the health and social consequences of each 
of the following types of substance use that accounts 
for their designation as risky substance use behaviors. 
§ Age 21 was selected because of the cultural marker 
of adulthood in the U.S., including the minimum 
legal drinking age, although research documents the 
continued development of the brain (and consequent 
vulnerability to the effects of addictive substances) 
into the mid-twenties. 



The notion of critical periods, so integral to the 
development of language or musical skills, is 
relevant to the development of addiction as 
well. It is clear from my work in addiction 
medicine that use of addictive substances is 
like a traumatic brain injury to a young person. 
Any use by young people before brain 
development is complete equals risky use. 161 

-Mark S. Gold, MD 
University of Florida College of Medicine and 
McKnight Brain Institute 
Departments of Psychiatry, Neuroscience, 
Anesthesiology, Community Health & 
Family Medicine 
Chairman, Department of Psychiatry 



-29- 



• Use of any addictive substance by pregnant 
women, for whom there is no known safe 
level of use. 

• Use of any tobacco product; there is no 
known safe level of use of tobacco products. 

• Alcohol use in excess of the established 
dietary guidelines for safe alcohol use of no 
more than one drink per day for women and 
two drinks per day for men, as described by 
the U.S. Departments of Agriculture 
(USDA) Dietary Guidelines.* 162 This 
includes the non-mutually exclusive 
categories of binge drinking, 1 heavy 
drinking* and heavy binge drinking. 5 

• Misuse (non-medical use) of controlled 
prescription drugs and over-the-counter 
medications**-i.e., using them for purposes 



The guidelines also stipulate no alcohol 
consumption for: (1) persons under the age of 21; (2) 
pregnant women; (3) individuals who cannot restrict 
their drinking to moderate levels; (4) individuals 
taking prescription or over-the-counter medications 
that can interact with alcohol; (5) individuals with 
certain specific medical conditions (e.g., liver 
disease, hypertriglyceridemia, pancreatitis); and (6) 
individuals who plan to drive, operate machinery or 
take part in other activities that require attention, skill 
or coordination, or in situations where impaired 
judgment could cause injury or death (e.g., 
swimming). Although drinking alcohol, as described 
in (4) through (6) is considered risky substance use, 
estimates of rates of risky substance use in this report 
do not include these criteria since they are not 
directly measured in the national surveys that were 
analyzed for this study. 
' Consuming five or more drinks on the same 
occasion (within a few hours) on at least one day in 
the past 30 days. 

* When a woman consumes more than three drinks on 
a given day or more than seven drinks during a given 
week or when a man consumes more than four drinks 
on a given day or more than 14 drinks during a given 
week. 

§ Binge drinking on at least five occasions in the past 
30 days. 

** In accordance with the federal Controlled 
Substances Act of 1970 which created a system for 
classifying illicit and prescription drugs according to 
their medical value and their potential for misuse. 



not prescribed or intended such as to get 
high, feel stimulated or sedated; taking more 
of the substance than prescribed or 
recommended; or taking the substance too 
often or for a longer period of time than was 
prescribed or recommended. ft 163 

• Use of non-prescribed federally controlled 
(illegal/illicit drugs) drugs; K there is no 
known safe level of use of these drugs. 



Addiction: A Medical Disease. At the end of 

the continuum of substance use are those who 
meet clinical criteria for addiction. Yet even 
among these individuals, there is tremendous 
variation in the severity and course of the 
disease. At the extreme end of the continuum is 



TT For data analysis purposes, the national survey 
examined for this report defines misuse of controlled 
prescription medications more generally as "taking a 
controlled prescription drug not prescribed for you or 
taking it in a manner not prescribed for the 
experience or feeling it causes." The misuse of over- 
the-counter medications also constitutes risky use; 
however, rates of risky substance use in this report do 
not include the misuse of these medications since 
they are not directly measured in the national surveys 
that were analyzed for this study. 
M Substances controlled (either through prohibited or 
restricted use) by the federal Controlled Substances 
Act of 1970 which created a system for classifying 
illicit and prescription drugs according to their 
medical value and their potential for misuse. In the 
analyses presented in this report, illicit drugs include 
marijuana/hashish, cocaine/crack, heroin, 
hallucinogens, Ecstasy, methamphetamine and 
inhalants. (See Chapter III.) 



The public, and treatment sources alike, often are 
confused as to the distinction among use, heavy 
use and addictive disease. 164 

-Stuart Gitlow, MD, MPH, MBA 
Executive Director 
Annenberg Physician Training Program in 
Addictive Disease 
Associate Clinical Professor 
Mount Sinai School of Medicine 
Acting President & AMA Delegate 
American Society of Addiction Medicine 



-30- 



the most severe form of the illness: chronic 
relapsing disease. 

There are two leading sources of diagnostic 
classifications for addiction (called substance 
use disorders): The American Psychiatric 
Association's Diagnostic and Statistical Manual 
of Mental Disorders (DSM-IV) and the World 
Health Organization's International Statistical 
Classification of Disease (ICD). Both reflect the 
historical classification of addiction as a mental 
disorder based on measures of its behavioral 
symptoms rather than the current science 
documenting the medical nature of the problem 
as an underlying brain disease. 166 

Diagnostic and Statistical Manual of Mental 
Disorders (DSM-IV). The DSM-IV is the main 
diagnostic reference of mental health 
professionals in the United States and presents 
three types of disorders that are drug specific: 
(1) alcohol use disorders, (2) drug use disorders 
and (3) nicotine dependence. Both alcohol and 
drug use disorders involve two levels of 
severity— abuse and dependence— while nicotine 
only involves dependence. The criteria for 
abuse are similar for alcohol and other drugs, 
and the criteria for dependence are similar for all 
three drug types. 167 

The DSM-IV defines substance abuse as "a 
maladaptive pattern of substance use leading to 
clinically significant impairment or distress." 168 
The term substance abuse, though widely used- 
and often used beyond its clinical definition to 
describe any kind of risky substance use-has 
become controversial due to its negative, value- 
laden and pejorative connotation. 169 

The term substance dependence is defined in the 
DSM-IV as ". . .a cluster of cognitive, behavioral 
and physiological symptoms indicating that the 
individual continues use of the substance despite 
significant substance-related problems." 170 



DSM-IV Criteria 165 
Substance Abuse 

To be diagnosed with substance abuse, an individual 
must exhibit one or more of the following four 
symptoms within a 12-month period:* 

• Recurrent use resulting in failure to fulfill major 
role obligations at work, school or home; 

• Recurrent use in physically hazardous 
situations; 

• Recurrent use resulting in legal problems; and 

• Continued use despite persistent or recurrent 
social or interpersonal problems. 

Substance Dependence 

To be diagnosed with substance dependence, an 
individual must exhibit three or more of seven 
symptoms within a 12-month period: 

• Tolerance— the need for markedly increased 
amounts of the substance to achieve intoxication 
or the desired effect or a markedly diminished 
effect with the continued use of the same 
amount of the substance; 

• Withdrawal-maladaptive behavioral change 
with co-occurring physiological and cognitive 
changes that occurs when use of a substance is 
reduced or discontinued, or usage of a substance 
to relieve or avoid withdrawal symptoms; 

• Taking increasing amounts or using the 
substance over a longer period than intended; 

• A persistent desire or unsuccessful efforts to 
reduce or control substance use; 

• Spending a significant amount of time in 
activities to obtain the drug, use it or recover 
from use; 

• Neglecting or giving up important social, 
occupational or recreational activities because of 
use; and 

• Continuing use of the substance despite 
knowledge of having a persistent or recurring 
physical or psychological problem that is caused 
or worsened by use. 



* The symptoms must never have met criteria for 
substance dependence for the class of substances 
used. 



-31- 



Definitional Problems . The first two symptoms 
of the DSM-IV's substance dependence 
diagnosis-tolerance and withdrawal— reflect 
physiological dependence on a substance as a 
result of its regular use. 171 There has been 
considerable confusion about the difference 
between physiological dependence on a 
substance and addiction involving that 
substance. This is further confused by the use of 
the same term "dependence" to apply to both 
conditions. 

According to the DSM-IV diagnostic criteria, 
tolerance and withdrawal symptoms neither are 
necessary nor sufficient for a diagnosis of 
substance dependence 112 (e.g., an individual may 
meet diagnostic criteria for addiction involving 
cocaine or methamphetamine in the absence of 
symptoms of tolerance and withdrawal). 173 
There also are cases where an individual is 
physically dependent on a substance but does 
not meet clinical criteria for addiction. 174 This 
occurs relatively frequently in relation to the use 
of controlled prescription pain relievers. 
Prolonged use of these medications may result in 
physical symptoms, including tolerance and 
withdrawal as a result of the body's adaptation 
to taking the drug, 175 but may not include the 
loss of control and other behavioral symptoms 
associated with addiction. 176 

Other symptoms of substance dependence also 
can be observed in patients legitimately using 
certain prescription medications. 177 For 
example, if a patient's pain is under- treated, he 
or she may become preoccupied with finding a 
pain medication or may take a pain medication 
for a longer time than originally was 
prescribed. 178 Mischaracterizing this behavior as 
addiction may result in further withholding of 
legitimate pain treatment/ 179 

Issues have been raised with regard to the 
reliability and validity of the nicotine 



Opioids. 

f While the under-treatment of pain has been 
acknowledged, there are emerging indications that 
many physicians may now be overprescribing 
addictive opioid medications for the treatment of 
patients with non-malignant chronic pain. 



dependence criteria as well: they have been 
described as ambiguous, failing to address 
important aspects of addiction involving nicotine 
such as craving, too subjective and intertwined 
with an individual's social context (e.g., with 
regard to assessing the "costs" of continued use) 
and limited in their ability to predict key 
outcomes such as extent of tobacco use, 
withdrawal severity and likelihood of future 
cessation. 180 

Proposed Modifications to the DSM Diagnostic 
Criteria . Partially because of these definitional 
problems, work is under way to redefine and 
reorganize the DSM's diagnostic criteria for 
substance use disorders. These revisions are 
proposed to be included in the upcoming DSM- 
V version, which is estimated to be released in 
May 20 13. 181 Among the proposed revisions is 
the suggestion to replace the two categories of 
substance abuse and substance dependence with 
a single diagnostic category of substance use 
and addictive disorders} 182 This modification 
recognizes a broad category of addiction 
including substance addiction and other 
compulsive behaviors that reflect a common 
neuropathology. 183 Separate disorders would be 
identified for each type of addictive substance or 
behavior and for multiple addictive disorders. 
The addictive disorder diagnosis would contain 
1 1 criteria; meeting two or three criteria would 
result in a diagnosis of "moderate" severity, 
while meeting four or more criteria would result 
in a diagnosis of "severe." The presence of 
physical dependence (symptoms of tolerance or 
withdrawal) also would be identified. § 184 



1 Initially, the Substance-Related Disorders Work 
Group for the revisions to the DSM considering 
renaming this category "Addiction and Related 
Disorders." 

§ The proposed revised criteria clearly state that 
tolerance and withdrawal are "not counted for those 
taking medications under medical supervision such as 
analgesics, antidepressants, anti-anxiety medications 
or beta-blockers." This stipulation is designed to 
prevent a patient who becomes physically dependent 
on a prescription drug received during the course of 
medical care from being diagnosed with addiction 
(i.e., a substance use disorder). 



-32- 



One issue being raised in the proposed revisions 
to the DSM is that of patients who are at 
heightened risk of developing addiction in the 
near future but do not now meet the diagnostic 
criteria. 185 One suggestion* is to add a severity 
category of "mild" to the proposed "moderate" 
and "severe" diagnosis categories. This 
modification would help to identify risky 
substance users and increase the chances that 
they receive needed services to prevent their 
risky use from progressing to addiction, while 
reducing the risk of their receiving unnecessary 
treatment which might accompany a more 
severe diagnosis. 186 

International Statistical Classification of 
Diseases (ICD). Like the DSM, the ICD does 
not present a disease category of addiction; 
rather, it presents mental health disorders that 
are linked to psychoactive substance use 
including nicotine, alcohol and other drugs. 187 

Like the DSM, the ICD offers two categories 
related to addiction: in this case, harmful use 
and dependence syndrome. Harmful use is 
defined as "a pattern of psychoactive substance 
use that is causing damage to health. The 
damage may be physical (e.g., hepatitis 
following injection of drugs) or mental (e.g., 
depressive episodes secondary to heavy alcohol 
intake)." The ICD defines dependence 
syndrome as "a cluster of behavioral, cognitive 
and physiological phenomena that may develop 
after repeated substance use. Typically, these 
phenomena include a strong desire to take the 
drug, impaired control over its use, persistent 
use despite harmful consequences, a higher 
priority given to drug use than to other activities 
and obligations, increased tolerance and a 
physical withdrawal reaction when drug use is 
discontinued." 188 

The DSM vs. the ICD. While there is 
considerable overlap between the diagnostic 
definitions provided in the DSM and the ICD, 
the ICD definitions connote more of a disease 
state while the DSM definitions imply more of a 
behavioral disorder. In addition, the ICD is used 



Made by NAADAC, the Association for Addiction 
Professionals. 



more frequently internationally while the DSM 
is used more frequently in the United States and 
Canada. 189 Access to the ICD codes is free to 
the public via the Internet, whereas providers 
must pay the American Psychiatric Association 
for access to the DSM manual and codes, either 
by purchasing the text version of the manual or 
by paying to access the information online. 190 
The DSM is used more commonly than the ICD 
in research studies, whereas the ICD has become 
the primary tool used by health care facilities to 
index health care data. 191 The DSM criteria for 
addiction involving nicotine are used less 
frequently by researchers and clinicians than 
criteria for addiction involving alcohol and other 
drugs; 192 

Like the DSM, the ICD currently is undergoing 
revisions and there is hope that the parties 
involved in the revisions to these classification 
systems will take the opportunity to standardize 
the language used to describe the full spectrum 
of clinical addiction, 193 with an increased focus 
on the disease itself rather than different 
disorders linked to specific substances. 

It also is important to clarify that addiction is a 
medical condition with significant behavioral 
components. 194 Recognizing that current 
diagnostic classification systems like the DSM 
and ICD do not sufficiently take into account the 
shared underlying genetic and neurobiological 
dimensions of addiction and various health 
conditions— instead relying primarily on 
subjective reports of symptoms of seemingly 
unique and unitary conditions-the National 
Institute of Mental Health (NIMH) has begun to 
classify these conditions in a new way. The 
Research Domain Criteria project (RDoC) aims 
to develop a classification system based on 
observable behavior and neurobiological 
measures that underlie different manifestations 
of addiction and related conditions which 
currently are classified and addressed as distinct 
conditions. 195 Should this new system take hold, 



1 Measures of addiction involving nicotine that are 
considered to have greater predictive validity in terms 
of outcomes include the Fagerstrom Test for Nicotine 
Dependence (TTND) and Nicotine Dependence 
Symptom Scale (NDSS). 



-33- 



it eventually may help practitioners diagnose 
and address the disease of addiction and its 
multiple manifestations in a more unified and 
coherent manner in clinical practice. 

Public Attitudes about Addiction 

Public attitudes about a particular disease or 
health condition and the people who suffer from 
it historically have been linked to the public's 
understanding of its causes and amenability to 
treatment. This nation has a long history of 
isolating and stigmatizing individuals with 
health problems that were not well understood, 
from tuberculosis to cancer, depression and 
HIV-AIDS. Once scientific understanding of 
the condition is solidified and the information 
permeates public understanding, public attitudes 
towards the condition and those who have it 
often change. The availability of effective 
treatments also can have a profound impact on 
driving this change. Addiction is a prime 
example of a disease where public attitudes have 
yet to catch up with the science, although 
attitudes are shifting. 196 

A 2005 online survey of 1,000 adults ages 20 
and older about addiction involving alcohol 
found that 63 percent of the general public see it 
primarily as a personal or moral weakness ( 1 9 
percent) or equally as a personal or moral 
weakness and as a disease or health problem (44 
percent); only 34 percent see it primarily as a 
disease or health problem. In contrast, only 1 1 
percent of individuals who are managing the 
disease (i.e., in recovery) see it either primarily 
as a personal or moral weakness (two percent) or 
as both a personal or moral weakness and a 
disease or health problem (nine percent); 81 
percent see it primarily as a disease or health 
problem. This survey also found that 43 percent 
of physicians consider addiction involving 
alcohol to be a personal or moral weakness (nine 
percent see it primarily as a personal or moral 
weakness and 34 percent see it equally as a 
personal or moral weakness and as a disease or 
health problem); 56 percent see it primarily as a 
disease or health problem. 197 



A more recent survey of treatment providers in 
the U.S. and the United Kingdom, published in 
201 1, found that the belief that addiction is a 
disease is stronger among those who provide 
for-profit treatment while the belief that 
addiction is a choice is stronger among providers 
of public or not-for-profit treatment* 198 — the 
more common form of treatment in the United 
States. 199 

Results from a nationally representative survey 
conducted in 2008 found that 44 percent of the 
public believes that people with addiction 
involving alcohol could stop drinking if they 
had enough willpower (73 percent of young 
adults, age 18 to 24, hold this view). Fewer 
Americans think the same is true for addiction 
involving other drugs (38 percent of the public; 
66 percent of young adults). 200 



A 2009 nationally representative survey of 1 ,000 
adults ages 1 8 and older underscores the 
tremendous stigma still associated with 
addiction: individuals with addiction involving 
alcohol or other drugs commonly were described 
by respondents with words such as "sinner," 
"irresponsible," "selfish," "stupid," "loser," 
"undisciplined," "pathetic" and "weak." 202 



Differences also were found between providers who 
were members of a group of addiction professionals, 
had been treating addiction for longer, had stronger 
spiritual beliefs, had a past addiction problem and 
were older (tending to endorse the belief that 
addiction is a disease) versus those who were not 
members of a group of addiction professionals, had 
less strong spiritual beliefs and were younger 
(tending to endorse the belief that addiction is a 
choice). 



The average person in the U.S. views addiction 
with a sense of hopelessness. They realize that 
not all users of alcohol or other addictive drugs 
will become addicted. They know that some 
users will become addicted but that others will 
not. This creates a belief that the addict can— 
and should— use willpower to stop using. 101 

- J. Paul Molloy, JD 
Chief Executive Officer 
Oxford House 



-34- 



However, as a sign of increasing acceptance of 
addiction as a disease, this same survey found 
that the majority (78 percent) regard addiction 
involving drugs other than nicotine or alcohol as 
a chronic disease. 203 Another 2009 nationally 
representative survey of adults ages 1 8 and older 
also found that the majority of the respondents 
believe that addiction is a health condition that 
requires ongoing attention and support (83 
percent). 204 

Perceived Causes of Addiction 

For decades, public misconceptions about the 
origins of addiction have led to negative 
attitudes and discrimination against those 
afflicted with the disease and hindered progress 
not only in understanding it, but also in 
developing and providing effective treatments 
for it. 205 In 2008, CASA Columbia probed these 
perspectives with a nationally representative 
survey of American attitudes toward substance 
use and addiction— the National Addiction Belief 
and Attitude Survey (NABAS). Although public 
attitudes increasingly appear to be reflective of 
the science of addiction, people still often hold 
conflicting views about the causes of addiction, 
many of which are inconsistent with the growing 
body of evidence. 

CASA Columbia's NABAS found, for example, 
that while many people understand that factors 
such as genetics, family history, other health 
problems and availability of addictive 
substances play a role in the development of 
addiction and that loss of control is a defining 
characteristic of the disease, a significant 
proportion of Americans cite "lack of will power 
or self-control" as a primary causal factor. 
Surprisingly, respondents who had a personal 
experience with addiction— either that of a 
family member or friend or their own— did not 
differ much from the general public in these 
perceptions of the key contributors to addiction. 
Respondents also had different views on the 
causes of addiction depending on the substance 
involved. 206 



Tobacco/Nicotine. Despite the fact that 
genetics account for up to 75 percent of the risk 
for addiction involving nicotine, 207 the NABAS 
found that only one in four respondents (25.4 
percent) cited "a predisposition to addiction, due 
to genetics or family history" as a primary 
causal factor when given a list of potential 
causes of addiction involving tobacco/nicotine. 
Respondents were most likely to cite an 
"inability to resist peer pressure" (43.5 percent); 
"easy availability of tobacco among youth" 
(38.7 percent); "stress or anxiety about work, 
family or other problems" (37.7 percent); and 
"lack of willpower or self-control" (33.0 
percent) as primary causal factors. 208 
(Figure 2. A) 



Figure 2.A 

Perceived Causes of Addiction 
Involving Tobacco/Nicotine 




Inability To Resist Peer Pressure 














P 
E 
R 

C 


Easy Availability 


I 38.7 






Stress/Anxiety 


| 37.7 


E 






N 


Lack of Willpower/Self-Control 


| 33.0 


T 


Predisposition/Genetics/ 
Family History 














Source: CASA Columbia National Addiction Belief and Attitude 
Survey (NABAS), 2008. 

Note 1 : Respondents could choose two or three answers. 

Note 2: Other research finds that genetics account for up to 75% of 

the risk of nicotine dependence. 





Alcohol. Public attitudes are more aligned with 
the science regarding the role of genetics in 
addiction involving alcohol. Genetics account 
for 48 to 66 percent of the risk that someone 
who drinks alcohol will become addicted 209 and 
nearly half (47.6 percent) of respondents to the 
NABAS cite "a predisposition to addiction, due 
to genetics or family history" as a primary 
causal factor. Other perceived primary causes of 
addiction involving alcohol include "stress or 
anxiety about work, family or other problems" 
(44.9 percent); "emotional disorders or mental 
illness, such as depression or anxiety" (35.3 
percent); "lack of willpower or self-control" 



-35- 



(29.7 percent); "easy availability of alcohol 
among youth" (29.2 percent); and "inability 
to resist peer pressure" (28.2 percent). 210 
(Figure 2.B) 

Other Drugs. Although genetic factors 
account for up to 78 percent of the risk for 
developing addiction involving illegal or 
controlled prescription drugs (depending on 
the type of drug studied and the severity of 
the addiction), 211 only 27.5 percent of 
NABAS respondents cited "a predisposition 
to addiction, due to genetics or family 
history" as a primary cause of addiction 
involving prescription drugs. The most 
commonly cited factor that may cause people 
to become addicted to prescription drugs was 
"emotional disorders or mental illness, such 
as depression or anxiety" (40.8 percent). 212 
Co-occurring mental health disorders do 
appear to play a significant role in the risk that 
drug use will progress to addiction. 213 Other 
primary causes that were mentioned by 
respondents to the NABAS include "stress or 
anxiety about work, family or other 
problems" (36.9 percent); "easy availability 
of prescription medications among youth" 
(36.7 percent); and a "lack of willpower or 
self-control" (26.9 percent). 214 (Figure 2.C) 

Thirty percent cited "a predisposition to 
addiction, due to genetics or family history" 
as a primary cause of addiction involving 
illegal drugs. The most commonly cited 
factor that may cause people to become 
addicted to illegal drugs was an "inability to 
resist peer pressure" (41.9 percent). Other 
factors that were mentioned as a primary 
cause of addiction involving illicit drugs 
include "easy availability of illegal drugs 
among youth" (35.1 percent); "emotional 
disorders or mental illness, such as depression or 
anxiety" (34.8 percent); "stress or anxiety about 
work, family or other problems" (29.9 percent); 
and a "lack of willpower or self-control" (28.7 
percent). 215 (Figure 2.D) 



Figure 2.B 

Perceived Causes of Addiction 
Involving Alcohol 



Predisposition/Genetics/ 
Family History 

Stress/Anxiety 
Emotional Disorders/Mental Illness 
Lack of Willpower/Self-Control 
Easy Availability 
Inability to Resist Peer Pressure 



□ 47.6 



3 44.9 



35.3 




| 29.7 
| 29.2 
28.2 



Source: CASA Columbia National Addiction Belief and Attitude 
Survey (NABAS), 2008. 

Note 1 : Respondents could choose two or three answers. 
Note 2: Other research finds that genetics account for 48% to 66% 
of the risk that someone who drinks alcohol will develop an addiction 
involving alcohol. 



Figure 2.C 

Perceived Causes of Addiction 
Involving Controlled Prescription Drugs 










Emotional Disorders/Mental Illness 


| 40.8 








P 


Stress/Anxiety 


| 36.9 


E 






R 


Easy Availability 


| 36.7 


C 


Predisposition/Genetics/ 
Family History 




E 
N 


| 27.5 


T 






Lack of Willpower/Self-Control 


| 26.9 










Source: CASA Columbia National Addiction Belief and Attitude Survey 
(NABAS), 2008. 

Note 1 : Respondents could choose two or three answers. 

Note 2: Other research finds that genetics account for up to 78% of the risk for 

the development of addiction involving prescription and other drugs. 



-36- 



Figure 2.D 

Perceived Causes of Addiction 
Involving Illegal Drugs 



Inability To Resist Peer Pressure 
Easy Availability 
Emotional Disorders/Mental Illness 

Stress/ Anxiety 

Predisposition/Genetics/ 
Family History 

Lack of Willpower/Self-Control 




Source: CASA Columbia National Addiction Belief and Attitude Survey 
(NABAS), 2008. 

Note 1 : Respondents could choose two or three answers. 

Note 2: Other research finds that genetics account for up to 78% of the 

risk for the development of addiction involving prescription and other 

drugs. 



The NABAS found little indication that 
respondents attribute addiction primarily to an 
"absence of religious faith or spiritual 
grounding" or to "distorted moral values." 216 



-37- 



-38- 



Chapter III 

Prevalence and Consequences 



More than one in seven (15.9 percent, 40.3 
million) people in the United States ages 12 and 
older currently meet clinical criteria for 
addiction* '--more than the share of the 
population with cancer, diabetes or heart 
disease. ' 2 An additional but unknown number 
of people have the disease but are managing it 
effectively and so do not meet these behavioral 
criteria. 1 3 Another third of the population (31.7 
percent, 80.4 million), while not addicted, 
currently 5 use one or more addictive substances 
in ways that threaten their own health and safety 
or the health and safety of others. 4 

Risky substance use and addiction are the largest 
preventable and most costly public health and 
medical problems in the U.S. 5 Together they are 
the leading causes of preventable death and 
cause or contribute to more than 70 other 
conditions requiring medical care. 6 The 
damaging effects of risky substance use and 
addiction extend to a wide range of costly social 



Defined as meeting criteria for past-month nicotine 
dependence based on the Nicotine Dependence 
Syndrome Scale (NDSS) and meeting diagnostic 
criteria for past year alcohol and/or other drug abuse 
or dependence (excluding nicotine) in accordance 
with the Diagnostic and Statistical Manual of Mental 
Disorders (DSM-IV). (The DSM refers to substance 
abuse and substance dependence collectively as 
substance use disorders. The criteria for nicotine 
dependence in the NDSS parallel those of the DSM- 
IV.) This estimate excludes the institutionalized 
population, for which rates of addiction are higher. 
f Includes coronary heart disease, angina pectoris, 
heart attack or any other heart condition or disease, 
excluding hypertension and stroke. 
* There are no national data on the proportion of the 
population that has been diagnosed with addiction 
and is effectively managing the disease. Existing 
national survey data indicate that 10 percent of adults 
ages 1 8 and older report that they "once had a 
problem with drugs or alcohol but no longer do" 
(sometimes referred to as "sustained recovery"), but 
it is not clear what proportion of this group ever was 
diagnosed with addiction as distinguished from 
"having a problem." 
§ In the past 30 days. 



-39- 



consequences including crime, lost productivity, 
child neglect and abuse, family dysfunction and 
developmental disabilities. 

Certain populations-including pregnant women, 
adolescents and young adults and the elderly- 
are more vulnerable to the damaging effects of 
addictive substances. Other populations- 
including those with co-occurring disorders, 
members of the military exposed to combat and 
those in the justice system— are more likely to 
engage in risky use or have addiction. 

Defining the Problem 

Substance use can be understood as a continuum 
ranging from having never smoked or used 
alcohol or another drug at one end to having an 
unmanaged chronic, relapsing disease f at the 
other. (Figure 3. A) 



Figure 3. A 

Continuum of Substance Use 

Percent of Population Age 12+ 
by Level of Sustance Use* 



12.7 


25.2 


14.5 




31.7 


Never 
Used 


No 
Current 
Use 


Non- 
Risky Use 


Risky 
Use 




15.9 

Addiction 



* Includes tobacco, alcohol, illicit drugs and misuse of 
controlled prescription drugs. 

Source: CASA Columbia analysis of The National Survey on 
Drug Use and Health (NSDUH), 2010. 



Most people (87.3 percent) ages 12 and older in 
the U.S. have used one or more addictive 



Including any use of illicit drugs or the misuse of 
controlled prescription drugs. 
' This continuum focuses on substance use; the 
category labeled addiction includes those individuals 
whose substance use meets current clinical criteria 
for this disease but does not include all individuals 
with addiction. There are some individuals with the 
disease of addiction who do not currently use any 
addictive substances and others who currently may fit 
into other use categories along the continuum. 



substances at some point in their lives, and 62. 1 
percent are current users. 1 7 Those who have 
never used an addictive substance, are not 
current users 5 or do not engage in risky 
substance use are appropriate targets for public 
health efforts aimed at preventing risky use and 
addiction; however, these individuals are not the 
focus of this report. 

While this report focuses primarily on those with 
the disease of addiction, it makes an important 
distinction between addiction and risky use of 
addictive substances: 

• Those with the disease of addiction are 
defined in this report as meeting the clinical 
diagnostic criteria for past month nicotine 
dependence or past year alcohol and/or other 
drug abuse or dependence. Individuals who 
meet diagnostic criteria for addiction are 
targets for appropriate, evidence-based 
clinical interventions by physicians and 
other health professionals. 

• Risky users of addictive substances are 
defined in this report as those who currently 
use tobacco products, exceed the U.S. 
Department of Agriculture (USDA) Dietary 
Guidelines for safe alcohol use,** 8 



1 Current substance use among the entire U.S. 
population ages 12 and older: 51.7 percent drink 
alcohol; 27.6 percent use tobacco products; 7.5 
percent use illicit drugs; and 2.8 percent misuse 
controlled prescription drugs. 
§ Having used the substance in the past 30 days. 

The U.S. Department of Agriculture Dietary 
Guidelines for safe alcohol use are no more than one 
drink a day for women, no more than two drinks a 
day for men and no alcohol consumption for: 
(1) persons under the age of 21; (2) pregnant women; 
(3) individuals who cannot restrict their drinking to 
moderate levels; (4) individuals taking prescription or 
over-the-counter medications that can interact with 
alcohol; (5) individuals with certain specific medical 
conditions (e.g., liver disease, hypertriglyceridemia, 
pancreatitis); and (6) individuals who plan to drive, 
operate machinery or take part in other activities that 
require attention, skill or coordination or in situations 
where impaired judgment could cause injury or death 
(e.g., swimming). Due to data limitations, we were 
unable to include categories 4-6 in our calculation of 
risky drinkers. 



-40- 



misuse controlled prescription drugs, use 
illicit drugs' 9 or engage in some 
combination of these forms of substance use 
but do not meet clinical diagnostic criteria 
for addiction. Risky use can result in 
devastating and costly health and social 
consequences, including the disease of 
addiction. Risky users are targets for public 
health efforts aimed at reducing risky use 
and of medical and other health professional 
efforts to prevent risky use from progressing 
to the disease of addiction. 



To determine the scope of risky substance use 
and addiction in the United States, CASA 
Columbia examined national prevalence data 1 
for the total U.S. non- institutionalized 
population ages 12 and older. For these 
analyses, we examined current (past 30 day) use 
of tobacco, alcohol and other drugs and the rate 
of addiction involving these substances. Our 
definition of addiction in this report is consistent 
with the parameters used in the national survey 
upon which our analyses are based-the National 
Survey on Drug Use and Health (NSDUH)— 
which categorizes respondents on the basis of 
diagnostic criteria used in the Nicotine 
Dependence Syndrome Scale (NDSS) for 
nicotine dependence and in the DSM-IV for 



alcohol and other drug abuse or dependence. 
We also examined variations in the rates of risky 
use and addiction by age, gender and race/ 
ethnicity. Because of the heightened 
vulnerability to addictive substances while the 
brain is still developing, 5 10 we present data for 
the following age groups: 12- to 17-year olds; 
18- to 25-year olds; and those ages 26 and older. 
While the NSDUH was used for these analyses 
to present consistent data across age groups, it is 
important to note that these data appear to 
underestimate rates of current substance use 
among adolescents by at least half" 11 

Risky Substance Users 



Approximately one-third (31.7 percent) of the 
U.S. population ages 12 and older (80.4 million 
people) currently' f use one or more addictive 
substances in ways that threaten their own health 
and safety-including increasing the risk of 
addiction— or the health and safety of others, but 
do not meet clinical criteria for addiction. 
(Table 3.1) Nearly one-third (30.6 percent) of 
risky users engage in risky use of two or more 
substances. Alcohol is the substance most 
frequently implicated in risky substance use, 
followed by tobacco. 12 



For data analysis purposes, the national survey 
examined for this report defines misuse of controlled 
prescription medications more generally as "taking a 
controlled prescription drug not prescribed for you or 
taking it in a manner not prescribed for the 
experience or feeling it causes." Fhe misuse of over- 
the-counter medications also constitutes risky use; 
however, rates of risky use in this report do not 
include the misuse of these medications since they 
are not measured directly in the national surveys that 
were analyzed for this study. 

' Substances controlled (either through prohibited or 
restricted use) through the federal Controlled 
Substances Act of 1970 which created a system for 
classifying illicit and prescription drugs according to 
their medical value and their potential for misuse. In 
this analysis, illicit drugs include marijuana/hashish, 
cocaine/crack, heroin, hallucinogens, Ecstasy, 
methamphetamine and inhalants. 
* Fhe most recent data available (2010) from the 
Substance Abuse and Mental Health Association's 
(SAMHSA) National Survey on Drug Use and 
Health (NSDUH). 



s See Chapter II. 

** Because the NSDUH is conducted in the home 
where an adult must be present, reported prevalence 
rates for teens are significantly lower than reported 
rates in school-based surveys where greater 
anonymity is assured. For example, the Youth Risk 
Behavior Survey's (YRBS) prevalence estimates for 
12- to 17-year olds are 2.15 to 2.75 times as high as 
those presented in the NSDUH. 
ff In the past 30 days. 



-41- 



Table 3.1 

Prevalence of Current Risky Use* of 
Addictive Substances in 
U.S. Population, Ages 12+, 2010 





Percent of 

Total 
Population 


Number 

(in 
Millions) 


Total Risky Use 


31.7 


80.4 


Tobacco With/Without 
Other Substances 


18.5 


47.0 


Tobacco Only 


6.7 


17.0 


AlCOilOl W llw W ltflOUt 
Winer oUDSiances 


27.2 


69.0 


Alcohol Only 


14.3 


36.2 


Illicit Drugs 
WithAVithout 
Other Substances 


5.8 


14.6 


Illicit Drugs Only 


0.6 


1.6 


Controlled Prescription 
Drugs With/Without 
Other Substances 


2.1 


5.4 


Controlled Prescription 
Drugs Only 


0.5 


1.1 


Multiple Substances 


9.7 


24.6 



Individuals included in the risky use category used 
the substance in the past 30 days but do not meet 
diagnostic criteria for addiction. 
Source: CASA Columbia analysis of The National 
Survey on Drug Use and Health (NSDUH), 2010. 

Young adults, ages 18- to 25- years old, are 
more likely to engage in risky substance use 
than any other age group. (Figure 3. B) Men are 
somewhat likelier to be risky substance users 
than women: 33.9 percent (41.8 million) vs. 
29.6 percent (38.6 million). 13 

Whites, Hispanics and blacks are likelier to 
engage in risky substance use than persons of 
other races/ethnicities.* 14 (Figure 3. C) 



Figure 3.B 

Current* Risky Substance Use 
Among Individuals Ages 12+, 2010 
Percent (Number in Millions) 



31.7 
(80.4 M) 



40.9 
(13.9 M) 



J 



14.3 

(3.5 M) 



r 



32.3 
(63.0 M) 



Total 



12 to 17 



18 to 25 



26+ 



* In the past 30 days. 

Source: CASA Columbia analysis of The National Survey on 
Drug Use and Health (NSDUH), 201 0. 



Figure 3.C 

Current* Risky Substance Use 
Among Individuals Ages 12+ by Race/Ethnicity, 
2010 

Percent (Number in Millions) 




White 



Black 



Hispanic 



Other 



* In the past 30 days. 

Source: CASA Columbia analysis of The National Survey on 
Drug Use and Health (NSDUH), 201 0. 



The proportion of the population engaging in 
risky substance use has remained stable over the 
past decade; in 2002, 31.1 percent (73.1 million) 
were risky substance users, as were 31.7 percent 
(80.4 million) in 20 10. 15 



"Other" races/ethnicities include American 
Indian/ Alaska Native, Asian, Native Hawaiian/Other 
Pacific Islander and multiracial non-Hispanic. These 
races/ethnicities were combined for purposes of 
analysis because there are too few respondents in 
each category to calculate meaningful prevalence 

data for each category separately. The "other 

races/ethnicities" category is reported as a group vary between each racial/ethnic group in this 

despite the fact that substance use prevalence rates category. 



-42- 



Risky Tobacco Use 

In 2010, 18.5 percent of the U.S. population 
ages 12 and older (47.0 million) reported current 
risky use* of a tobacco product: 



Risky tobacco use is slightly higher among 
blacks than among whites and Hispanics; risky 
use in these groups is higher than among persons 



of other races/ethnicities. 20 (Figure 3.E) 



• Cigarettes: 14.0 percent (35.5 
million); 

• Cigars: 4.2 percent (10.6 million); 

• Smokeless tobacco products: 3.0 
percent (7.7 million); and 

• Pipe tobacco: 0.7 percent (1.7 
million). 1 16 

The majority (59.1 percent) of risky 
tobacco users* also are risky users of 
alcohol or other drugs. While not having 
addiction involving nicotine, 18.2 
percent of risky tobacco users have 
addiction involving alcohol and/or other 
drugs. 17 

Among all age groups, 18- to 25- year 
olds have the highest rate of risky 
tobacco use. 18 (Figure 3. D) 

Men are nearly twice as likely as women 
to be risky tobacco users (24.1 percent, 
29.7 million vs. 13.3 percent, 17.3 
million). 19 



Figure 3.D 

Current* Risky Tobacco Use 
Among Individuals Ages 12+, 2010 
Percent (Number in Millions) 



30.4 
(10.4 M) 



18.5 
(47.0 M) 







9.0 
(2.2 M) 



17.6 
(34.5 M) 



Total 



12 to 17 



18 to 25 



26+ 



* In the past 30 days. 

Source: CASA Columbia analysis of The National Survey on 
Drug Use and Health (NSDUH), 201 0. 



Figure 3.E 

Current* Risky Tobacco Use 
Among Individuals Ages 12+ by Race/Ethnicity, 
2010 

Percent (Number in Millions) 



18.7 
(31.8 M) 


20.5 
(6.2 M) 


18.2 
(6.7 M) 














13.8 














(2.3 M) 






















White 



Black 



Hispanic 



Other 



* In the past 30 days. 

Source: CASA Columbia analysis of The National Survey on 
Drug Use and Health (NSDUH), 201 0. 



Used a tobacco product in the past 30 days but do 
not meet criteria for addiction involving nicotine 
(i.e., nicotine dependence, as defined by the NDSS). 
' These percentages represent the proportion of the 
U.S. population ages 12 and older reporting risky use 
of each type of tobacco product. These percentages 
do not add up to the total of 18.5 percent because of 
multiple substance use. Nationally representative 
data on the use of water/ hookah pipes to smoke 
tobacco are not available. 
* Who do not have addiction involving nicotine. 



-43- 



Between 2002 and 2010, risky tobacco use in the 
U.S. population ages 12 and older decreased 
slightly, from 19.9 percent (46.8 million) in 
2002 to 18.5 percent (47.0 million) in 2010. 
Among adolescents (ages 12 to 17), the decrease 
in risky tobacco use was more pronounced, from 
12.0 percent in 2002 to 9.0 percent in 20 10. 21 

Risky Alcohol Use" 

In 2010, 27.2 percent of the U.S. population 
ages 12 and older (69.0 million) were current 
risky drinkers: 22 

• 24.2 percent were age 21 and older who, on 
average, exceeded the USDA guidelines for 
safe alcohol use; 

• 2.9 percent were under age 21 and drank 
alcohol; and 

• 0. 1 percent were adult pregnant women who 
drank alcohol. ' 23 

Within this population of risky drinkers: 

• 69.6 percent 1 were heavy drinkers- 
consuming more than three drinks on any 
day or more than seven drinks in any week 
for women, and more than four drinks on 



any day or more than 14 drinks in any week 
for men; § 

• 65. 1 percent** were current binge drinkers- 
consuming five or more drinks on the same 
occasion on at least one day in the past 30 
days; and 

• 14.7 percent' ' were current heavy binge 
drinkers-binge drinking on at least five days 
in the past 30 days. K 24 

More than half (52.6 percent) of all current 
drinkers are risky drinkers. Nearly half (46.4 
percent) of risky drinkers §§ also are risky users 
of tobacco or other drugs. While not having 
addiction involving alcohol, 14.2 percent of 
risky drinkers have addiction involving nicotine 
and/or other drugs. 25 

As with tobacco, 18- to 25-year olds have the 
highest rates of risky alcohol use. 26 One in 10 
adolescents ages 12 to 17 are risky drinkers.*** 27 
(Figure 3.F) 



Based on the USDA Guidelines for safe alcohol use 
described on page 40. Excluded from the category of 
risky drinkers are those who meet diagnostic criteria 
for addiction involving alcohol in the past year. 
Because the analyses were restricted 
to the data available in the NSDUH, the component 
of risky alcohol use that reflects the USDA 
guidelines of no more than one drink a day for 
women and two for men was measured by the item: 
"On the days that you drank during the past 30 days, 
how many drinks did you usually have?" As such, it 
represents the average amount respondents drink on 
days that they drink. If a woman drinks, on average, 
more than one drink a day on days that she drinks or 
if a man drinks, on average, more than two drinks a 
day on days that he drinks, she or he would be 
considered a risky drinker in this analysis. 
' A portion of this category is included in the adult 
risky drinker category above. 
* 18.9 percent of the population (ages 12 and older), 
48.0 million people. 



§ Due to limitations of the NSDUH data set, weekly 
consumption was computed as an average of monthly 
drinking divided by 4.33, or 52 weeks / 12 months. 
** 17.7 percent of the population, 44.9 million people. 
^ 4.0 percent of the population, 10.1 million people. 
** Rates of heavy, binge, and heavy binge drinkers 
include only risky alcohol users who do not have 
addiction involving alcohol. 
§§ Who do not have addiction involving alcohol. 

For individuals under age 2 1 , any alcohol use (in 
the past 30 days) that does not meet criteria for 
addiction is considered risky drinking. 



-44- 



Figure 3.F 

Current* Risky Alcohol Use 
Among Individuals Ages 12+, 2010 
Percent (Number in Millions) 



40.2 
(13.7 M) 



27.2 



1 



) 




27.1 
(52.9 M) 


10.2 
(2.5 M) 










I 



Total 



12 to 17 



1 8 to 25 



26+ 



* In the past 30 days. 

Source: CASA Columbia analysis of The National Survey on 
Drug Use and Health (NSDUH), 2010. 



Those ages 1 8 to 25 engage in binge and heavy 
binge drinking at significantly higher rates than 
those ages 26 and older.* 28 (Table 3.2) 



More men than women engage in risky drinking 
(28.3 percent, 34.9 million vs. 26.2 percent, 34.1 
million). This difference becomes more 
pronounced at higher levels of drinking: men 
are almost twice as likely as women to be heavy 
drinkers (23.8 percent vs. 14.3 percent) and 
binge drinkers (23.6 percent vs. 12.1 percent), 
and three times as likely to be heavy binge 
drinkers (6.2 percent vs. 1.9 percent). 29 

Overall, whites are more likely to engage in 
risky drinking compared to persons of other 
races/ethnicities; however, Hispanics are slightly 



Other national data indicate that while the 
prevalence and intensity of binge drinking is highest 
among individuals ages 18 to 34, adults ages 65 and 
older who binge drink do so more frequently than any 
other age group. Data regarding involvement in each 
type of substance in this table and in subsequent 
tables demonstrating demographic differences are 
presented as any involvement with the substance 
(with or without involvement with other substances) 
because presenting risky use for each substance on its 
own (without other substance involvement) results in 
cell sizes that are too small to present reliable data. 
As such, data on specific substances and multiple 
substances shown in the tables are not mutually 
exclusive. 



more likely to engage in heavy and binge 



drinking. 30 (Table 3.3) 



Table 3.2 

Prevalence of Current Heavy, Binge and Heavy 
Binge Drinking,* by Age, 2010 
Percent (Number in Millions) 





Heavy 


Binge 


Heavy 




Drinking 


Drinking 


Binge 








Drinking 


Total Heavy, Binge, 








and Heavy Binge 


18.9 


17.7 


4.0 


Drinking, Ages 12+ 


(48.0 M) 


(44.9M) 


(10.1M) 


Age: 








12- to 17-years old 


5.2 


5.0 


0.8 


18- to 25-years old 


28.8 


28.0 


7.3 


26+ years old 


18.9 


17.5 


3.8 



Were risky users of alcohol in the past 30 days but do not 
meet diagnostic criteria for addiction involving alcohol. 
Source: CASA Columbia analysis of The National Survey on 
Drug Use and Health (NSDUH), 2010. 

Table 3.3 

Prevalence of Current Risky, Heavy, Binge and 
Heavy Binge Drinking,* by Race/Ethnicity, 2010 
Percent (Number in Millions) 



Total Risky 
Alcohol Use 



Heavy Drinking 



Binge Drinking 



Heavy Binge 
Drinking 



White 



28.5 
(48.4M) 



19.7 



18.1 



4.7 



Black Hispanic Other 



24.9 
(7.5M) 



16.0 



15.6 



2.2 



27.0 
(9.9M) 



20.7 



20.1 



2.9 



19.2 
(3.2M) 



12.6 



11.9 



1.9 



Were risky users of alcohol in the past 30 days but do not 
meet diagnostic criteria for addiction involving alcohol. 
Source: CASA Columbia analysis of The National Survey on 
Drug Use and Health (NSDUH), 2010. 



Between 2002 and 2010, risky alcohol use in the 
U.S. population ages 12 and older increased 
slightly, from 26.4 percent (62.0 million) in 
2002 to 27.2 percent (69.0 million) in 20 10. 31 
This increase was consistent across all forms of 
risky drinking: 

• Heavy drinking, from 18.2 percent to 18.9 
percent; 



-45- 



• Binge drinking, from 16.9 percent to 17.7 
percent; and 

• Heavy binge drinking from 3.8 percent to 
4.0 percent. 32 

Risky Illicit Drug Use 

In 2010, 5.8 percent of the U.S. population ages 
12 and older (14.6 million) reported current 
risky use of illicit drugs,* primarily marijuana: 33 

• Marijuana/hashish: 5.6 percent (14.2 
million); 

• Cocaine/crack: 0.3 percent (0.8 million); 

• Hallucinogens: 0.3 percent (0.8 million); 

• Ecstasy: 0.2 percent (0.4 million); and 

• Inhalants: 0.2 percent (0.5 million).* 34 

Nearly all risky illicit drug users (81.6 percent) 
also are risky users of tobacco, alcohol or 
controlled prescription drugs. While not having 
addiction involving illicit drugs, 40.3 percent 
has addiction involving nicotine, alcohol and/or 
controlled prescription drugs. 35 

Risky use of illicit drugs is highest among 1 8- to 
25-year olds; adolescents ages 12 to 17 are more 
likely to be risky users of illicit drugs than adults 
ages 26 and older. (Figure 3.G) Risky 
marijuana use follows the same pattern, with 
13.6 percent (4.7 million) of 18- to 25-year olds, 
4.9 percent (1.2 million) of 12 to 17-year-olds 
and 4.0 percent of those ages 26 and older (7.9 
million) engaging in risky use of marijuana/ 36 



Used an illicit drug in the past 30 days but do not 
have addiction involving illicit drugs. Data on the 
risky use of methamphetamine and heroin cannot be 
reported separately due to small sample size. 
' These percentages do not add up to the total of 5.8 
percent because of multiple substance use. 
* Data on the risky use of other types of illicit drugs 
cannot be reported separately by age, gender or 
race/ethnicity due to small sample sizes. 



Men are nearly twice as likely as women to be 
risky users of illicit drugs (7.5 percent, 9.3 
million vs. 4.1 percent, 5.3 million). Men also 
are nearly twice as likely as women to be risky 
marijuana users (7.1 percent, 8.8 million vs. 3.8 
percent, 4.9 million). 37 

Blacks and whites are more likely to engage in 
risky use of illicit drugs than Hispanics or 
persons of other races/ethnicities. 38 (Figure 3.H) 



Figure 3.G 

Current* Risky Illicit Drug Use 
Among Individuals Ages 12+, 2010 
Percent (Number in Millions) 



14.2 
(4.8 M) 



5.8 
(14.6 M) 



5.8 
(1.4 M) 




4.3 
(8.4 M) 



Total 



12 to 17 



18 to 25 



26+ 



* In the past 30 days. 

Source: CASA Columbia analysis of The National Survey on 
Drug Use and Health (NSDUH), 2010. 



Figure 3.H 

Current* Risky Illicit Drug Use 
Among Individuals Ages 12+ by Race/Ethnicity, 
2010 

Percent (Number in Millions) 




White 



Black 



Hispanic 



Other 



* In the past 30 days. 

Source: CASA Columbia analysis of The National Survey on 
Drug Use and Health (NSDUH), 201 0. 



-46- 



With regard to the risky use of marijuana 
specifically, blacks are more likely to be risky 
users (6.3 percent, 1.9 million), than whites (5.7 
percent, 9.8 million), Hispanics (4.1 percent, 1.5 
million) or persons of other races/ethnicities (3.3 
percent, 0.6 million). 39 

The rate of risky use of illicit drugs has 
increased slightly between 2002 (5.0 percent, 
11.9 million) and 2010 (5.8 percent, 14.6 
million) driven primarily by an increase in the 
rate of risky use of marijuana (4.6 percent, 10.7 
million in 2002 and 5.6 percent, 14.2 million in 
20 10). 40 

Risky Use of Controlled Prescription Drugs 

In 2010, 2.1 percent of the U.S. population ages 
12 and older (5.4 million) reported risky use of 
controlled 1 prescription drugs, with opioids 
(pain relievers) the most frequently misused: 41 

• Opioids: 1.6 percent (3.9 million); 

• Tranquilizers: 0.6 percent (1.5 million); and 

• Stimulants: 0.3 percent (0.7 million). i 42 

Of those who are risky users sS of controlled 
prescription drugs, 65.8 percent (3.6 million) 
also are risky users of tobacco, alcohol or illicit 
drugs. While not having addiction involving 
controlled prescription drugs, 43.6 percent of 
risky users of these drugs have addiction 
involving nicotine, alcohol and/or an illicit 
drug. 43 



Risky use of controlled prescription drugs is 
highest among 18- to 25-year olds; more 12- to 
17-year olds report risky use of these drugs than 



those ages 26 and older. 44 (Figure 3.1) 



Figure 3.1 

Current* Risky Use of 
Controlled Prescription Drugs 
Among Individuals Ages 12+, 2010 
Percent (Number in Millions) 



4.3 
(1.5 M) 



2.1 
(5.4 M) 



2.3 
(0.6 M 



1.7 
(3.4 M) 



Total 



12to 17 



18 to 25 



26+ 



* In the past 30 days. 

Source: CASA Columbia analysis of The National Survey on 
Drug Use and Health (NSDUH), 201 0. 



This pattern is the same for the risky use of 
opioids specifically: 2.0 percent of 12- to 17- 
year olds, 3.2 percent of 18- to 25-year olds and 
1.2 percent of individuals ages 26 and older are 
risky users of opioids.** 45 

Men are slightly likelier to be risky users of 
controlled prescription drugs (2.3 percent, 2.8 
million) than women (2.0 percent, 2.6 million). 
With regard to opioids, men also are more likely 
to be risky users (1.8 percent, 2.2 million) than 
women (1.3 percent, 1.7 million). 46 



Misused a controlled prescription drug in the past 
30 days but do not have addiction involving 
prescription drugs. 

' Controlled by the U.S. Drug Enforcement 
Administration because of their potential for misuse. 
* Data on the risky use of sedatives cannot be 
reported separately due to small sample size. These 
percentages do not add up to the total of 2. 1 percent 
because of multiple substance use. 
§ Who do not have addiction involving prescription 
drugs. 



Data on the risky use of other classes of controlled 
prescription drugs cannot be reported separately by 
age, gender or race/ethnicity due to small sample 
size. 



-47- 



Whites are more likely to be risky users of 
controlled prescription drugs than persons of 
other races/ethnicities. 47 (Figure 3. J) 



Figure 3. J 

Current* Risky Use of 
Controlled Prescription Drugs 
Among Individuals Ages 12+ by Race/Ethnicity, 
2010 

Percent (Number in Millions) 



2.3 
(3.9 M) 



1.7 
(0.5 M) 



2.1 
(0.8 M) 



_□ 



1.3 
(0.2 M) 



White 



Black 



Hispanic 



Other 



* In the past 30 days. 

Source: CASA Columbia analysis of The National Survey on 
Drug Use and Health (NSDUH), 201 0. 



Addictioiv 

In 2010, a total of 15.9 percent of the U.S. 
population ages 12 and older (40.3 million 
people) met clinical diagnostic criteria for 
addiction. 1 50 

Addiction involving nicotine and alcohol are the 
most prevalent manifestations of addiction, 
followed by addiction involving illicit drugs and 
controlled prescription drugs. 51 (Table 3.4) 



However, with regard to the specific case of 
opioids, Hispanics are slightly likelier than 
whites (1.7 percent, 0.6 million vs. 1.6 percent, 

2.8 million)* to misuse opioids. 48 

The rate of risky use of controlled prescription 
drugs has remained relatively stable between 
2002 (2.2 percent, 5.2 million) and 2010 (2.1 
percent, 5.4 million); the rate of risky use of 
opioids also has remained stable between 2002 
(1.5 percent, 3.6 million) and 2010 (1.6 percent, 

3.9 million). 49 



Data on risky opioid use among blacks (1.3 percent) 
and persons of other races/ethnicities (1.0 percent) 
cannot be reported as statistically significant due to 
small sample sizes. 



' The term "addiction" is used synonymously in this 
report with the NDSS criteria for past 30 day nicotine 
dependence, and the DSM-IV clinical diagnostic 
criteria for past year alcohol and/or other drug abuse 
and dependence (excluding nicotine) in accordance 
with the Diagnostic and Statistical Manual of Mental 
Disorders (DSM-IV). (The DSM refers to substance 
abuse and substance dependence collectively as 
substance use disorders. The diagnostic criteria for 
nicotine dependence in the NDSS parallel those of 
the DSM-IV). These are the criteria used by the 
NSDUH to classify respondents as having a 
substance use disorder. This definition is consistent 
with the current move to combine abuse and 
dependence into an overarching diagnosis of 
addiction in the upcoming DSM-V. Available data 
allow us to include in our prevalence estimates only 
those who meet behavioral criteria in accordance 
with the current diagnostic standards, meaning that 
their disease is not effectively managed or has not 
reached the point of behavioral symptoms. 
Individuals who have the disease of addiction but do 
not meet diagnostic criteria for past month (nicotine) 
or past year (alcohol or other drug) addiction are not 
included. 

* This estimate excludes the institutionalized 
population, for which rates of addiction are higher. 



-48- 



Table 3.4 
Prevalence of Addiction in 
U.S. Population, Ages 12+, 2010 





Percent oi 


XT 1_ 

Number 




Total 


s 




Population 


Millions) 


Total AHHirtinn* 






Nicotine With/ Without 


9.0 


22.9 


Other Substances 


Nicotine Only 


7.1 


18.0 


Alcohol With/Without 


7.1 


18.0 


Other Substances 


Alcohol Only 


5.0 


12.6 


Illicit Drugs 






With/Without Other 


2.2 


5.6 


Substances 






Illicit Drugs Only 


0.8 


2.1 


Controlled Prescription 






Drugs With/Without 


0.9 


2.4 


Other Substances 






Controlled Prescription 
Drugs Only 


0.2 


0.6 


Multiple Substances 


2.7 


7.0 



Based on past 30-day nicotine dependence, as defined 
in the NDSS, and past-year alcohol and/or other drug 
abuse or dependence, as defined in the DSM-IV. 
Source: CASA Columbia analysis of The National 
Survey on Drug Use and Health (NSDUH), 2010. 



Those ages 1 8 to 25 have the highest rate of 
addiction, including the highest rates involving 
each type of substance, than any other age 



group. 53 (Figure 3.K; Table 3.5 T ) 



Figure 3.K 

Addiction Among Individuals Ages 12+, 2010 
Percent (Number in Millions) 



26.4 

(9.0 m; 



15.9 
(40.3 M) 



D 



8.0 
(2.0 M) 



15.0 
(29.3 M) 



Total 



12 to 17 



18 to 25 



26+ 



Source: CASA Columbia analysis of The National Survey on 
Drug Use and Health (NSDUH), 201 0. 



Among those with addiction, 55.7 percent are 
risky users of one or more other substances and 
17.3 percent have addiction involving multiple 
substances, including: 

• 21.3 percent of those with addiction 
involving nicotine; 



• 30. 1 percent of those with addiction 
involving alcohol; 



• 75.2 percent of those with addiction 
involving controlled prescription drugs; and 

• 62. 1 percent of those with addiction 
involving illicit drugs. 52 



Met diagnostic criteria for two or more of the 
following: past 30-day nicotine dependence and/or 
past year abuse/dependence involving alcohol, illicit 
drugs and/or controlled prescription drugs. 



1 Data regarding addiction involving each type of 
substance in this table and in subsequent tables 
demonstrating demographic differences are presented 
as addiction involving the substance, with or without 
addiction involving other substances, because 
presenting addiction related to each substance on its 
own (without other substance addiction) results in 
cell sizes that are too small to present reliable data. 
As such, data on specific substances and multiple 
substances shown in the tables are not mutually 
exclusive. 



-49- 



Table 3.5 

Prevalence of Addiction, by Age Group, 2010 
Percent (Number in Millions) 





12- to 


18- to 


26+ 




17- years 
old 


25- years 
old 


years 
old 


Total Addiction, 


8.0 


26.4 


15.0 


Ages 12+ 


(2.0M) 


(9.0M) 


(29.3M) 


Nicotine With/Without 








Other Substance 








Addiction 


1.8 


10.4 


9.7 


Alcohol With/Without 








Other Substance 








Addiction 


4.6 


15.8 


5.9 


Illicit Drugs 








With/Without Other 








Substance Addiction 


4.1 


6.5 


1.2 


Controlled Prescription 








Drugs With/Without 








Other Substance 








Addiction** 


(1.2) 


(2.2) 


(0.7) 


Multiple Substances 


2.7 


6.7 


2.1 



Based on past 30-day nicotine dependence, as defined in 
the NDSS, and past-year alcohol and/or other drug abuse 
or dependence, as defined in the DSM-IV. 

The rate of addiction involving controlled prescription 
drugs is too low to assure statistical reliability of data by 
age. 

Source: CASA Columbia analysis of The National Survey 
on Drug Use and Health (NSDUH), 2010. 

It is important to note that 8.0 percent of 
adolescents ages 12 to 17 have addiction. 54 The 
percent of adults who meet clinical criteria for 
addiction declines with age.* The explanation 
for this is not well understood and reliable 
national data are not available on the proportion 
of those with addiction for whom the disease is 
chronic. It may be that some young people 
receive treatment or otherwise successfully 
manage the disease to the point where they no 
longer meet diagnostic criteria for addiction as 
they get older, while for some other young 
people the disease may be fatal. 



Men are more likely to have addiction than 
women (19.1 percent, 23.6 million vs. 12.8 
percent, 16.6 million). While rates of addiction 
involving nicotine and controlled prescription 
drugs are similar for both genders, rates of 
addiction involving all other substances are 
twice as high among men as women. 55 
(Table 3.6) 

Table 3.6 

Prevalence of Addiction," by Gender, 2010 
Percent (Number in Millions) 



Total Addiction, 
Ages 12+ 



Nicotine With/Without Other 
Substance Addiction 



Alcohol With/Without Other 
Substance Addiction 



Illicit Drugs With/Without 
Other Substance Addiction 



Controlled Prescription Drugs 
With/Without Other 
Substance Addiction 



Multiple Substances 



Males Females 



19.1 

(23.6M) 



9.9 



9.5 



2.9 



(1.1) 



3.5 



12.8 
(16.6M) 



8.2 



4.8 



1.6 



(0.8) 



2.0 



Based on past 30-day nicotine dependence, as 
defined in the NDSS, and past-year alcohol and/or 
other drug abuse or dependence, as defined in the 
DSM-IV. 

** The rate of addiction involving controlled 
prescription drugs is too low to assure statistical 
reliability of data by gender. 

Source: CASA Columbia analysis of The National 
Survey on Drug Use and Health (NSDUH), 2010. 



23.7 percent (8.6 million) of adults ages 26-34; 
16.8 percent (10.5 million) of adults ages 35-49; 
13.8 percent (7.9 million) of adults ages 50-64; and 
5.8 percent (2.3 million) of adults ages 65 and older. 



-50- 



Whites are more likely to have addiction than 
individuals of other races/ethnicities. Rates of 
addiction involving nicotine are highest among 
whites, while rates of addiction involving 
alcohol are highest among whites and Hispanics. 
Rates of addiction involving illicit drugs are 
highest among blacks. 56 (Table 3.7) 

Between 2002 and 20 1 0, the rate of addiction 
declined from 17.6 percent (41.4 million) to 15.9 
percent (40.3 million), driven primarily by the 
decline in rates of addiction involving nicotine 
(10.5 percent in 2002 to 9.0 percent in 2010). 57 

Special Populations 

Certain populations-such as pregnant women, 
the young and the elderly-are more vulnerable 
to the damaging and addictive effects of 
tobacco, alcohol and other drugs. Among 
individuals with co-occurring disorders, 
members of the military exposed to combat and 
persons involved in the justice system, the 
likelihood of risky use and addiction is 
significantly higher than in the general 
population. 

Pregnant Women 

In 2010, 16.2 percent of pregnant women were 
risky users of tobacco, alcohol or other drugs 
and 14.7 percent of pregnant women met clinical 
criteria for addiction. ' Although pregnant 
women are less likely to engage in risky 
substance use or have addiction than non- 
pregnant women, 58 any substance use by 
pregnant women is concerning because of the 
risk of pregnancy complications, adverse health 
consequences for the fetus and health and 
behavioral consequences for children prenatally 
exposed to addictive substances. 59 

Adolescents and Young Adults 

Use of tobacco, alcohol and other drugs while 
the brain is still developing increases the risk of 
addiction. Because the brain continues to 



Compared to 34.2 percent of non-pregnant women. 
Compared to 16.2 percent of non-pregnant women. 



Table 3.7 

Prevalence of Addiction,* by Race/Ethnicity, 2010 
Percent (Number in Millions) 





White 


Black 


Hispanic 


Other 


Total Addiction, 
Ages 12+ 


17.6 
(29.9M) 


13.4 
(4.0M) 


12.9 
(4.7M) 


9.9 
(1.6M) 


Nicotine With/ 
Without Other 
Substance Addiction 


10.9 


6.9 


4.2 


4.9 


Alcohol With/ Without 
Other Substance 
Addiction 


7.4 


5.8 


7.6 


5.0 


Illicit Drugs With/ 
Without Other 
Substance Addiction 


1.9 


3.5 


2.9 


1.6 


Controlled Prescription 
Drugs With/Without 
Other Substance 
Addiction 


(1.0) 


(0.6) 


(1.0) 


(0.7) 


Multiple Substances 


2.9 


2.9 


2.4 


2.0 



Based on past 30-day nicotine dependence, as defined in the 
NDSS, and past-year alcohol and/or other drug abuse or dependence, 
as defined in the DSM-IV. 



The rate of addiction involving controlled prescription drugs is too 
low to assure statistical reliability of data by race/ethnicity. 
Source: CASA Columbia analysis of The National Survey on Drug 
Use and Health (NSDUH), 2010. 



develop into the mid-20s, the use of tobacco, 
alcohol, controlled prescription drugs and illicit 
drugs among 12- to 25-year olds is a significant 
public health concern. 60 Despite this, risky 
substance use is high in this age group: 

• About half (50.6 percent, 29.6 million) of 
12- to 25-year olds have used a tobacco 
product 1 in their lifetime; 

• Two-thirds (64.9 percent, 37.9 million) of 
12- to 25-year olds have used alcohol in 
their lifetime; 

• Four in 10 (40.6 percent, 23.7 million) 12- 
to 25-year olds have used an illicit drug in 
their lifetime; and 

• Approximately one-fifth (21.0 percent, 12.3 
million) of 12- to 25 -year olds have misused 



1 Includes cigarettes, cigars, pipes and smokeless 
tobacco. 



-51- 



a controlled prescription drug in their 
lifetime. 61 

Older Adults 

The body's tolerance to addictive substances 
declines with age, 62 while the quantity and 
frequency of prescription drug use typically 
increases. 63 These factors contribute to an 
increased chance of risky substance use and 
addiction. Also, as the "Boomer" generation 
ages, seniors are reporting increasingly higher 
rates of substance use and addiction, due to the 
higher rates of substance use in this age cohort 
compared with prior generations. 64 Currently, 
25.2 percent of the population ages 50 and older 
engages in risky substance use and 10.6 percent 
has addiction.* 65 

Co-occurring Disorders 

Addiction frequently co-occurs with other health 
conditions. 66 CASA Columbia's analysis of 
national data indicates that in the past year, 57.5 
percent of non-institutionalized individuals ages 
18 and older f with addiction also have another 
health condition: 

• 31.9 percent have been told by a doctor that 
they have a medical condition 4 (not 
including mental health disorders); and 

• 39.4 percent meet clinical criteria for a 
mental health disorder. § 67 (Figure 3.L) 



The sample size is too low to provide any further 
statistically reliable data on older adults ages 65 and 
older. 

' Data on mental health disorders among 12- to 17- 
year olds are not available in the NSDUH. 
* In the past year. Includes asthma, bronchitis, 
cirrhosis of the liver, diabetes, heart disease, 
hepatitis, high blood pressure, HIV/AIDs, lung 
cancer, pancreatitis, pneumonia, STDs, sinusitis, 
sleep apnea, stroke, tinnitus, tuberculosis and ulcer. 
§ Includes those with a current or past year mental, 
behavioral or emotional disorder (e.g., depression and 
anxiety; excluding developmental disorders and 
addiction) that meets DSM-IV criteria, or those with 
a major depressive episode in the past year. 



Figure 3.L 

Rates of Mental Health Disorders Among 
Individuals Ages 18+ with Addiction Involving 
Specific Substances, 2010 
Percent (Number in Millions) 



71.2 
(1.5 M) 



39.4 
(15.1 M) 



57.2 
(2.6 M) 



44.5 
(7.5 M) 



37.0 
(8.3 M) 



Total 



Controlled 
Prescription 
Drugs 



llicit Drugs Alcohol 



Nicotine 



Source: CASA Columbia analysis of The National Survey on 
Drug Use and Health (NSDUH), 201 0. 



People with mental health disorders also are 
more likely to be risky substance users and to 
have addiction than those without a mental 
health disorder. Among those ages 1 8 and older 
who have a mental health disorder, 30.6 
percent are risky substance users and 31.4 
percent have addiction. 68 

In total, 6.6 percent of the non-institutionalized 
U.S. population ages 18 and older (15.1 million) 
meet clinical criteria for both addiction and a 
mental health disorder. ' ' 69 Those with co- 
occurring addiction and mental health disorders 
also are likelier to have other co-occurring 
chronic illnesses such as hypertension, asthma 
and arthritis. 



70 



The rates of co-occurring mental health 
disorders appear to be even higher among people 
seeking treatment for addiction. One large-scale 
study of adolescents and adults in addiction 
treatment found that two-thirds of the patients 
had co-occurring mental health disorders in the 
year prior to treatment admission, with 18- to 
25 -year olds most likely to have co-occurring 



20.9 percent of adults (18 and older) in the U.S. 
population meet clinical criteria for a mental health 
disorder. 

11 These rates are higher among institutionalized 
persons; for example, CASA Columbia's 2010 study, 
Behind Bars Update: Substance Abuse and America's 
Prison Population, found that 24.4 percent of prison 
and jail inmates have both addiction and a co- 
occurring mental health disorder. 



-52- 



disorders. Attention deficit/hyperactivity 
disorder and conduct disorder are the most 
common co-occurring mental health disorders in 
young patients being treated for addiction, and 
anxiety and depression are the most common co- 
occurring mental health disorders in older 
patients; trauma-related disorders are common 
across age groups. 71 

The link between mental illness and smoking is 
particularly striking; 72 individuals age 1 8 and 
older with a mental illness involving serious 
functional impairment' are nearly twice as likely 
as those without such illnesses to have smoked 
cigarettes in the past year (49.8 percent vs. 27.4 
percent). 73 Up to 60 percent of those with 
depression, up to 70 percent of those with 
bipolar disorder and up to 88 percent of those 
with schizophrenia either are current or former 
smokers. 1 74 Those with clinical anxiety 5 are 
approximately twice as likely to be current 
smokers (39.2 percent vs. 22.2 percent), have 
smoked twice as many cigarettes in the past 
month (139.5 cigarettes vs. 63.4 cigarettes) and 
are more than twice as likely to have addiction 
involving nicotine (21.2 percent vs. 8.4 percent) 
as smokers without anxiety. Slightly more 
than one-quarter of the population (26.9 percent) 
has addiction, a mental health disorder or a 
serious mental illness,' ' yet this group smokes 
72.9 percent of all cigarettes. 75 



Ages 17 and younger. 

' National data from 2010. A diagnosable mental, 
behavioral or emotional disorder (excluding 
developmental disorders and addiction involving 
alcohol or drugs other than nicotine) of sufficient 
duration to meet diagnostic criteria specified in the 
DSM-IV that has resulted in serious functional 
impairment, substantially interfering with or limiting 
one or more major life activities. Comparable data 
are not available for 12- to 17-year olds. 
* These data are from a review of studies of clinical 
and population-based samples. 
§ Ages 12 and older. 

Among smokers, those with anxiety smoked an 
average of 355.5 cigarettes in the past month 
compared to 286.2 cigarettes among smokers without 
anxiety. 

' r A mental, behavioral or emotional disorder that has 
resulted in serious functional impairment which 
substantially interferes with or limits one or more 
major life activities. 



Members of the Military Exposed to 
Combat 

Exposure to combat increases the risk of 
addiction and co-occurring mental health 
problems such as post-traumatic stress disorder 
(PTSD), anxiety and depression. Addiction 
involving alcohol is one of the most commonly- 
reported disorders among Vietnam War 
veterans, 76 and co-occurring addiction and 
mental health disorders are most prevalent 
among veterans of the Vietnam era. 77 Military 
personnel and veterans of the more recent 
conflicts in Afghanistan and Iraq also are at 
increased risk of risky use and addiction as well 
as co-occurring mental health disorders. 78 

A study of smoking among individuals who 
were deployed or not deployed to Iraq and 
Afghanistan found that those who were 
deployed were more likely than those who were 
not deployed to initiate smoking if they never 
smoked before (2.3 percent vs. 1.3 percent), to 
resume smoking if they had smoked in the past 
(39.4 percent vs. 28.7 percent) and to have a 
greater increase in their smoking rate if they 
were smokers (57 percent vs. 44 percent). The 
same study found that those who were deployed 
and reported combat exposure were 1.6 times 
more likely to initiate smoking (among never- 
smokers) and 1.3 times more likely to resume 
smoking (among past smokers) compared to 
those who were not exposed to combat. The 
likelihood of resumption of smoking post- 
deployment was associated with length of 
deployment. ;t 79 

One study using data from 2005 found that 40 
percent of veterans from military operations in 
Iraq and Afghanistan who sought Veterans 
Administration (VA) health care screened 
positive for risky alcohol use and 22 percent 
screened positive for addiction involving 



11 More than nine months and deploying multiple 
times. 



-53- 



alcohol. Another study found that the 
prevalence of risky alcohol use* was higher after 
deployment to Iraq or Afghanistan compared to 
pre-deployment. 81 A study of soldiers who were 
interviewed three to four months after returning 
from deployment to Iraq found that 25 percent 
engaged in risky alcohol use. § Soldiers who had 
higher rates of exposure to threats of injury or 
death were more likely to engage in risky 
alcohol use. 82 A study of reserve/National 
Guard and active duty personnel found that 
reserve/National Guard personnel who were 
deployed with combat exposure were 1.6 times 
more likely than those deployed without combat 
exposure to experience new-onset heavy weekly 
drinking (8.8 percent vs. 5.6 percent) and 1.5 
times more likely to report new-onset binge 
drinking' ' (25.6 percent vs. 19.3 percent); active 
duty personnel who were deployed to Iraq or 
Afghanistan and reported combat exposure were 
1.3 times more likely than those who were 
deployed without combat exposure to report 
new-onset binge drinking (26.6 percent vs. 22.0 
percent). 83 A study of National Guard Brigade 
Combat Team soldiers deployed to Iraq from 
March 2006 to July 2007 found that 13 percent 



Based on scores on a version of the AUDIT 
instrument (see Appendix H). Risky drinking was 
defined as an AUDIT-C score of three or higher for 
women and four or higher for men. Addiction was 
defined as an AUDIT-C score of four or higher for 
women and six or higher for men. 
1 Of four U.S. combat infantry units (three Army 
units and one Marine Corps unit). 
* Measured with a two-question instrument asking, 
"In the last year, have you ever drunk or used more 
drugs than you meant to?" and "Have you felt you 
wanted or needed to cut down on your drinking or 
drug use in the last year?" 

§ Answering yes either to: "In the past four weeks, 
have you felt you wanted or needed to cut down on 
your drinking?" or "In the past four weeks, have you 
used alcohol more than you meant to?" 

Men who consumed more than 14 drinks per week 
and women who consumed more than seven drinks 
per week. 

n Those who reported drinking five or more drinks 
(for men) or four or more drinks (for women) on at 
least one day of the week or those who reported 
"drinking five or more alcoholic beverages" on at 
least one day or occasion during the past year. 



met criteria for addiction involving alcohol 
when they returned from deployment.* 1 84 

The risky use of prescription drugs also is 
common among active duty personnel. One 
study found that in 2008, 9.9 percent of service 
members misused prescription drugs §§ (14.5 
percent of Army, 9.1 percent of Navy, 10.2 
percent of Marine Corps, 7.5 percent of Air 
Force and 8.0 percent of Coast Guard service 
members), 85 a rate far higher than the 2.1 percent 
who have misused controlled prescription drugs 
in the general population. 86 

Soldiers exposed to combat who experience a 
traumatic brain injury (TBI) are at particularly 
high risk for the risky use of alcohol or other 
drugs and for addiction. One study of service 
members who were discharged from military 
service found that those with mild TBI were 2.6 
times more likely and those with moderate TBI 
were 5.4 times more likely to be discharged for 
addiction involving alcohol or for drug use 
compared to the total discharge population. 87 
Another study of service members with blast- 
induced mild-to-moderate injuries between 2004 
and 2007 found that more than six percent of 
service members with a mild TBI had post- 
deployment addiction involving alcohol. 88 

Post-traumatic stress disorder (PTSD) also is 
prevalent in the military population and co- 
occurs at high rates with addiction. One study 
of Iraq and Afghanistan veterans who were first- 
time users of VA health care, found that among 
those who met criteria for addiction involving 
alcohol and/or other drugs, 63 to 76 percent also 
met diagnostic criteria for PTSD. 89 



** Sixty-two percent of these soldiers met criteria 
prior to deployment while 38 percent had a new 
onset— that is, they met criteria post-deployment. 
§§ In the past 30 days, misused prescription-type 
amphetamines/ stimulants (including 
methamphetamine), tranquilizers/muscle relaxers, 
barbiturates/sedatives or opioids/pain relievers. 



-54- 



Involvement in the Justice System 

Adolescents (ages 12 to 17) who have a lifetime 
history of arrest are three times more likely to 
engage in risky substance use or have addiction 
compared with adolescents who have no arrest 
record (60. 1 percent vs. 19.8 percent). 90 They 
are: 



• Twice as likely to be risky substance users 
(24.5 percent vs. 13.7 percent); and 

• Five-and-a-half times as likely to have 
addiction (35.6 percent vs. 6.2 percent). 91 

Previous research by CASA Columbia has found 
that 78.4 percent of 10- to 17-year olds who are 
in juvenile justice systems are substance- 
involved;* 92 52.4 percent of juvenile or youthful 
offenders incarcerated in state prisons and local 
jails meet clinical criteria for addiction involving 
alcohol or other drugs. 93 

Those ages 1 8 and older who have ever been 
arrested are almost twice as likely to engage in 
risky substance use or have addiction compared 
to those with no arrest record (74.5 percent vs. 
45.0 percent). More specifically, while they are 
slightly more likely to be risky substance users 
without having addiction (38.1 percent vs. 32.5 
percent), they are three times as likely to meet 
diagnostic criteria for addiction (36.4 percent vs. 
12.5 percent). 94 



They were under the influence of alcohol or other 
drugs while committing their crime, test positive for 
drugs, are arrested for committing an alcohol or other 
drug offense, admit having substance-related 
problems or addiction or share some combination of 
these characteristics. 



Previous research by CASA Columbia found 
that the majority (84.8 percent) of all inmates are 
substance involved; 1 64.5 percent of the inmate 
population (nearly 1.5 million people) has 
addiction involving alcohol or drugs other than 
nicotine/ 

Consequences of Risky Substance 
Use and Untreated Addiction 

A broad range of health and social consequences 
result from risky substance use and addiction, 
including those discussed above for special 
populations. 96 Risky substance use and 
addiction constitute the largest preventable 
public health problems and the leading causes of 
preventable death in the U.S. 97 Of the nearly 2.5 
million deaths in 2009, an estimated minimum 
of 578,819 were attributable to tobacco, alcohol 
or other drugs. 5 98 (Table 3.8) 



' They had a history of using illicit drugs regularly, 
met clinical criteria for addiction, were under the 
influence of alcohol or other drugs when they 
committed their crime, had a history of alcohol 
treatment, were incarcerated for an alcohol or other 
drug law violation, committed their offense to get 
money to buy drugs or had some combination of 
these characteristics. 

* Due to data limitations, the estimated rate of 
addiction in the adult inmate population does not 
include nicotine dependence. However, other 
research suggests that the rate of tobacco use in the 
justice population is higher than in the general 
population. For example, in 2005, 37.8 percent of 
state inmates and 38.6 percent of federal inmates 
smoked in the month of their arrest. In contrast, the 
current smoking rate in the general population at that 
time was approximately 10 percentage points lower 
(24.9 percent). 

§ These numbers do not reflect the share of deaths 
from a wide range of other health conditions 
attributable to risky substance use and addiction. 



-55- 



Table 3.8 

Deaths Attributable to Substance Use 





Deaths/Year 


Total Deaths Attributable to 


578,819 


Substance Use 




Tobacco 


443,000 


Alcohol 


98,334 


Other drugs 


37,485* 



Based on data from 2009. 
Sources: Tobacco— Centers for Disease Control and 
Prevention (2008); Alcohol-CASA Columbia 
analysis of the Alcohol and public health: Alcohol- 
Related Disease Impact (ARDI) (2012); Other 
Drugs— Centers for Disease Control and Prevention 
(2010); Kochanek, K„ et al. (2011). 

Four out of every 10 (39.6 percent) fatal traffic 
crashes involve a driver who is under the 
influence of alcohol or who tested positive for 
other drugs. 



Overdose deaths caused by controlled 
prescription drugs and illicit drugs have 



increased five-fold since 1990 luu and now 
surpass the total number of deaths caused by 



traffic accidents. 



101 



Individuals with addiction are at increased risk 
of potentially fatal diseases including cancer, 102 
heart disease 103 and sexually-transmitted 
diseases. 104 More specifically, smoking 
contributes to multiple types of cancer as well as 
heart and respiratory disease. 105 Alcohol 
contributes to some of the leading causes of 
death, including heart disease, cancer and stroke, 
as well as to other serious illnesses such as 
cirrhosis, hepatitis and pancreatitis. 106 Injection 
drug use contributes to HIV, hepatitis C and 
hepatitis B. 107 CASA Columbia's research 
found that risky substance use and addiction 
cause or contribute to more than 70 other 
conditions requiring medical care, including 
cancer, respiratory disease, cardiovascular 
disease, pregnancy complications, HIV/AIDS, 
cirrhosis, ulcers and trauma. 108 (See Table 3.9) 



The many negative consequences of our failure 
to prevent risky substance use and treat 
addiction extend beyond the individual to 
family, friends, community and society. 109 
Risky substance use and untreated addiction 
contribute to family dysfunction and financial 
troubles, disrupted social relationships, unsafe 
sexual practices, unplanned pregnancies, lost 
work productivity, legal problems, poor 
academic and career performance, 
homelessness, property and violent crimes, 
domestic violence, child abuse and neglect, 
rapes and other sexual assaults and motor 
vehicle crashes and fatalities. 



no 



Risky substance use and addiction adversely 
affect the mental health of other family members 
as well. Family members ages 1 9 and older are 
at approximately twice the risk of having 
addiction or clinical depression as those ages 1 9 
and older in families without a member with 
addiction, and they have higher health care 
costs. 111 

Children and adolescents are particularly 
vulnerable to the health consequences of 
substance use. 1 12 Approximately 70 percent of 
child welfare cases are caused or exacerbated by 
parental risky use and addiction. 113 Children 
exposed to parental substance use are at 
increased risk of emotional and behavioral 
problems, conduct disorder, poor developmental 
outcomes and risky substance use and addiction 
in adolescence and adulthood. 114 Children and 
adolescents with family members who have 
addiction are more likely to be diagnosed with a 
number of medical conditions, including asthma, 
depression, headaches, attention deficit/ 
hyperactivity disorder, trauma and addiction, 
than children in families of similar demographic 
characteristics who do not have a member with 
addiction. 115 



Has a blood alcohol concentration of 0.08 or higher. 



-56- 



Table 3.9 

Conditions Requiring Medical Care Attributable to Risky Use and Addiction 



Tobacco-Related Conditions 


Malignant neoplasm (Cancer) 


Cardiovascular disease 


Perinatal conditions 


Lip, oral cavity, pharynx 


Ischemic heart disease 


Short gestation, low birth weight 


Esophagus 


Other heart disease 


Respiratory distress syndrome 


Stomach 


Cerebrovascular disease 


Other respiratory 


Pancreas 


Aortic aneurysm 




Larynx 


Other circulatory disease 




Trachea/lung/bronchus 


Respiratory diseases 




Cervix uteri 


Pneumonia, influenza 




Kidney and renal pelvis 


Bronchitis, emphysema 




Urinary bladder 


Chronic airway obstruction 




Acute myeloid leukemia 






Alcohol-Related Conditions 


Acute pancreatitis 


Laryngeal cancer 


Acute Conditions 


Alcohol abuse/Alcohol dependence syndrome 


Liver cancer 


Air-space transport 


Alcohol cardiomyopathy 


Liver cirrhosis unspecified 


Alcohol poisoning 


Alcohol polyneuropathy 


Oropharyngeal cancer 


Aspiration 


Alcohol-induced chronic pancreatitis 


Portal hypertension 


Child maltreatment 


Alcoholic gastritis 


Prostate cancer (males only) 


Drowning 


Alcoholic liver disease 


Psoriasis 


Excessive blood alcohol level 


Alcoholic myopathy 


Spontaneous abortion (females only) 


Fall injuries 


Alcoholic psychosis 


Stroke hemorrhagic 


Fire injuries 


Breast cancer (females only) 


Stroke ischemic 


Firearm injuries 


Cholelithiases 


Supraventricular cardiac dysrhythmia 


Homicide 


Chronic hepatitis 




Hypothermia 


Chronic pancreatitis 


Prenatal, infant 


Motor-vehicle non-traffic crashes 


Degeneration of nervous system due to alcohol 


Birth trauma 


Motor-vehicle traffic crashes 


Epilepsy 


Digestive 


Occupational and machine injuries 


Esophageal cancer 


Hemorrhage/hemolysis/endocrine/ 
jaundice/hematologic 


Other road vehicle crashes 


Esophageal varices 


Hypoxia/asphyxia/respiratory 


Poisoning (not alcohol) 


Fetal alcohol syndrome 


Infections 


Suicide 


Gastro esophageal hemorrhage 


Integument/temperature regulation 


Water transport accident 


Hypertension 


Length of gestation and fetal growth 




Ischemic heart disease 


Low birth weight/prematurity/ 
intrauterine growth restriction death 




Other Drug-Related Conditions* 






Drug-induced psychosis 


HIV/AIDS 


Other infectious diseases 


Hepatitis 


Inflammatory and toxic neuropathy 




* Other-drug related conditions also may include kidney, liver and respiratory diseases as well as the accident, suicide and poisoning 


categories listed above in the Alcohol-Related Conditions section. 




Sources: Centers for Disease Control and Prevention. (2004b); Centers for Disease Control and Prevention. (2008a); Centers for Disease 


Control and Prevention. (2008b); Merrill, J. & Fox, K. (1998); The National Center on Addiction and Substance Abuse (CASA) at 


Columbia University. (1993); The National Center 


on Addiction and Substance Abuse (CASA) at Columbia University. (1994). 



-57- 



Tobacco 

Tobacco use is the leading preventable cause of 
death and disability in the United States. An 
estimated one in five, or 443,000, deaths each 
year are attributable to cigarette smoking and 
exposure to tobacco smoke; 116 nearly 400,000 
deaths per year are attributable to smoking- 
related diseases. 1 7 (Table 3.10) 



Table 3.10 

Average Tobacco- Attributable Deaths Due to 
Smoking-Related Disease in the 
United States, 2000-2004 
Select Examples" 





Average Deaths 




Per Year 


total 


392,683 


Cancers: 


160,848 


Lung, trachea, bronchus 


125,522 


Esophagus 


8,592 


Pancreas 


6,683 


Urinary bladder 


4,983 


Lip, oral cavity, pharynx 


4,893 


Kidney, renal pelvis 


3,043 


Larynx 


3,009 


Stomach 


2,484 


Acute myeloid leukemia 


1,192 


Cervix, uterus (females only) 


447 


Cardiovascular Diseases: 


128,497 


Ischemic heart disease 


80,005 


Other heart disease 


21,004 


Cerebrovascular disease 


15,922 


Aortic Aneurysm 


8,419 


Atherosclerosis 


1,893 


Other arterial disease 


1,254 


Respiratory Diseases: 


392,683 


Chronic airway obstruction 


78,988 


Bronchitis, emphysema 


13,927 


Pneumonia, influenza 


10,423 



These data do not reflect all tobacco-attributable deaths. 
For example, deaths due to secondhand smoke and fire 
burn are not included. 

Source: Centers for Disease Control and Prevention 



(2011). 



Although the prevalence of tobacco use has 
declined over the past two decades, 121 mortality 
rates have remained constant due to an increase 
in population size, the identification of new 
diseases linked to smoking and the fact that 
cohorts that smoked heavily during their lifetime 
are now reaching an age with the highest 
incidence of smoking-attributable diseases. 122 

Over approximately the past four decades,* an 
estimated 94,000 infant deaths have been linked 
to prenatal exposure to smoking. 123 Pregnant 
women who smoke put their babies at increased 
risk for a host of health problems including 
placenta previa, ' stillbirth and sudden infant 
death syndrome (SIDS). 124 Smoking during 
pregnancy increases the risk for preterm birth 125 
and pregnant smokers are 1.6 times more likely 
to have a low birth weight baby than pregnant 
nonsmokers (1 1.9 percent vs. 7.5 percent). 126 
Merely reducing the number of cigarettes 
women smoke during pregnancy results in birth 
weight gain; but even light smokers* are twice as 
likely as nonsmokers to have low birth weight 
infants. § 127 Low birth weight is a leading risk 
factor for neonatal and infant mortality, can 
result in restricted childhood development and 
increases the risk of chronic disease, 
developmental delays and cognitive 

1 7 8 

impairment. 

The negative long-term health consequences for 
children exposed to prenatal smoking include 
increased risk for substance-related problems, 
depression, 129 attention deficit/hyperactivity 
disorder, conduct disorders and childhood 
obesity. 130 The nicotine in tobacco products can 
produce structural and chemical changes in the 
developing adolescent brain and make young 
people who smoke vulnerable to future addiction 
and to certain forms of mental illness, including 
panic attacks, panic disorder and other anxiety 
disorders. 131 



Tobacco use contributes to approximately 30 
percent of cancer and heart disease-related 
deaths 118 and numerous other health conditions 
including respiratory illness and chronic kidney 
disease. 119 An estimated 8.6 million Americans 
suffer from a serious smoking-related illness. 120 



* 1964 to 2004. 

' The complete or partial obstruction of the cervical 
opening by the placenta. 

* Smoke less than half a pack a day. 

§ In a study of low-income black women. 



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There also are serious health consequences for 
nonsmokers exposed to environmental tobacco 
smoke (ETS). 132 Children exposed to ETS are at 
increased risk of developing acute lower 
respiratory infections, ear infections, asthma and 
chronic respiratory symptoms, 133 and of 
becoming smokers and developing asthma in 
adulthood. 134 Exposure to ETS increases the 
risk of lung, breast and other cancers, heart 
disease, stroke and respiratory illnesses. 135 

Recently, the term "third-hand smoke" has been 
developed to describe the invisible but toxic 
gases and particles— including heavy metals, 
carcinogens and radioactive materials— that form 
a residue on smokers' hair, clothing and 
household items and remain for weeks or 
months after the second-hand smoke has 
cleared. 136 Like second-hand smoke, third-hand 
smoke is a cancer risk. 137 

Alcohol 

Alcohol use is the third leading cause of death in 
the United States (after tobacco use and poor 
diet/physical inactivity) and is responsible for 
approximately 3.5 percent of all deaths. 138 An 
estimated 98,334 people die from alcohol- 
related causes in the U.S. each year, including 
chronic diseases (e.g., liver disease, cancer) and 
acute causes (e.g., accidents, homicides). 139 
(Table 3.11) 

Of the 13,555 substance-related traffic fatalities 
in 2009, 10,185 involved drivers who were 
alcohol impaired (BAC of .08 or higher). 140 
Young people are at greater risk of becoming a 
victim of an alcohol-related traffic fatality 
compared to older people. 141 In 2009, 35 
percent of 21- to 24-year old drivers involved in 
fatal motor vehicle traffic crashes were under the 
influence of alcohol, more than any other age 
group.' 142 



* Had a BAC of .08 or higher. 

1 Compared to 19 percent of 15- to 20-year olds; 

33 percent of 25- to 29-year olds; 29 percent of 30- to 

34-year olds; 26 percent of 35- to 44-year olds; 22 

percent of 45- to 54-year olds; 13 percent of 55- to 

64-year olds; and 7 percent of 65- to 74-year olds. 



Table 3.11 

Average Alcohol-Attributable Deaths in the 
United States 2001-2005, 
Select Examples 





Average Deaths 




Per Year 


Total 


98,334 


Chronic Causes; 




Alcoholic liver disease 


12,219 


Stroke hemorrhagic 


8,725 


Liver cirrhosis, unspecified 


7,055 


Esophageal cancer 


4,225 


Alcohol denendence svndrome 


3,857 


Liver cancer 


3,431 


Breast cancer (females only) 


1,835 


Oropharyngeal cancer 


1,528 


Laryngeal cancer 


1,460 


Hypertension 


1,480 


Prostate cancer (males only) 


1,025 


Acute Causes: 




Motor-vehicle traffic crashes 


13,819 


Homicide 


7,787 


Suicide 


7,235 


Fall injuries 


5,532 


Poisoning (not alcohol) 


5,416 


Fire injuries 


1,158 


Drowning 


868 


Alcohol poisoning 


370 


Hypothermia 


269 


Aspiration 


204 


Child maltreatment 


168 



Source: CASA Columbia analysis of the Alcohol and 
public health: Alcohol-Related Disease Impact (ARDI). 

In 2009, alcohol was reported in at least one- 
quarter (24.3 percent) of substance-related 
emergency department (ED) visits. 1 These 
reports, however, significantly underestimate the 
prevalence of alcohol-related emergency 
department visits for two reasons: the data set 
does not include visits linked to alcohol use in 
combination with other drugs for persons under 
the age of 2 1 , and many EDs do not screen for 



* Measured in terms of patient visits, not individual 
drug reports. The analyses of the Substance Abuse 
and Mental Health Services Administration, Drug 
Abuse Warning Network (DAWN) data assess the 
number of drug mentions associated with a drug- 
related emergency department visit; up to four drugs 
plus alcohol may be recorded for each drug-related 
visit. 



-59- 



substance use because of state laws that exclude 
alcohol and other drug-related injuries from 
medical insurance coverage.* 143 

Risky alcohol use and addiction involving 
alcohol are associated with neurological 
problems including dementia, stroke and 
neuropathy; 144 cardiovascular problems 
including myocardial infarction, 
cardiomyopathy, atrial fibrillation and 
hypertension; 145 psychiatric problems including 
depression, anxiety and suicide; 146 liver diseases 
including hepatitis and cirrhosis; 147 and 
gastrointestinal problems including pancreatitis 
and gastritis. 148 Other associated conditions 
include increased risk of cancer of the liver, 
breast, mouth, throat, esophagus and colon, 149 
and recent research suggests that risky alcohol 
use may contribute to the physiological process 
that causes cancer cells to metastasize. 150 

Heavy alcohol use during pregnancy is 
associated with miscarriage and stillbirth and is 
one of the primary causes of severe mental and 
developmental delays in infants. 151 Fetal alcohol 
syndrome (FAS) is the leading known cause of 
preventable mental retardation. 152 

Illicit Drugs 

In 2008,' there were an estimated 16,044 deaths 
attributed to the use of illicit drugs. 153 Of the 
13,555 substance-related traffic fatalities in 
2009, 5,938 involved drivers impaired either by 
illicit drugs alone (3,146 deaths) or illicit drugs 
in combination with alcohol (2,792 deaths). 154 

In 2009, illicit drugs were involved in an 
estimated 973,591 emergency department 
visits;* accounting for 35.9 percent of substance- 
related ED visits; 155 cocaine, marijuana and 



* In 25 states, Uniform Accident and Sickness Policy 
Provision Laws (UPPL) exclude alcohol and other 
drug-related injuries from medical insurance 
coverage, creating a barrier to conducting screening 
for risky substance use (see Chapters IV and X). 

' Most recent available data that distinguishes 
between illicit and controlled prescription drugs. 

* Measured in terms of patient visits, not individual 
drug reports. 



heroin were the most frequently mentioned illicit 
drugs. 156 

Injection drug use behavior— including sharing 
needles and other injection paraphernalia—is 
associated with the spread of HIV/AIDS. 157 It is 
estimated that more than one-third of all AIDS- 
related deaths in the U.S. have occurred among 
illicit drug users and their sexual partners. 158 

Morbidity (secondary illness) and mortality 
(death) data related to illicit drug use may 
represent the direct pathological effects or 
medical toxicities from the drug (e.g., cocaine 
producing seizures or strokes or inhalants 
producing cardiac arrhythmias that can lead to 
sudden cardiac deaths), but also the infections 
transmitted via drug self-administration (e.g., 
intravenous or intramuscular self- 
administration). 159 

Marijuana use is associated with sexually 
transmitted disease due to unsafe sexual 
behaviors engaged in while under the influence 
of the drug, bronchitis and lung cancer; cocaine 
use is associated with pancreatitis; heroin use is 
associated with hepatitis and tuberculosis; 
hallucinogen use is associated with tinnitus and 
sexually transmitted disease; and inhalant use is 
associated with HIV/AIDS, sexually transmitted 
disease, tuberculosis, bronchitis, asthma, 
sinusitis and tinnitus. 5 160 

Illicit drug use also is linked to mental health 
problems. Marijuana use is associated with the 
onset of psychotic disorders, particularly in 
individuals with an underlying vulnerability to 
the illness; 161 several longitudinal studies have 
linked marijuana use with the subsequent onset 
of schizophrenia, and case studies have linked 
synthetic cannabinoids with psychosis. 162 
Marijuana and inhalant use are associated with 



These health consequences are associated primarily 
with long-term use of illicit drugs. The analyses 
adjusted for potentially confounding factors such as 
the duration of controlled prescription drug misuse, 
alcohol use, tobacco use, daily cigarette smoking 
history and demographic variables (age, gender, 
race/ethnicity, educational attainment, health 
insurance status and family income). 



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anxiety and depression, and cocaine and heroin 
use are associated with anxiety.* 163 

Methamphetamine, cocaine and other stimulant 
use (including the use of amphetamine-related 
and other "designer drugs") are associated with 
violent behavior, hallucinations, paranoia and 
delusions which can be acute time-limited 
symptoms or which can persist long after the 
cessation of use. f 164 There is a range of 
substance-induced disorders included in the 
DSM-IV that reflect secondary mental health 
effects of addictive substance use. 165 

Approximately 160,000 pregnancies in 2004 
were associated with illicit drug use. 166 Illicit 
drug use during pregnancy increases the risk of 
neurological and cognitive deficits in the fetus 
and future behavior problems. 167 Heavy 
marijuana use has been associated with low birth 
weight, premature delivery and complications in 
delivery. 168 Marijuana and cocaine exposure 
have been linked to impaired attention, language 
and learning skills, as well as to behavioral 
problems. 169 

Infants exposed to prenatal illicit drug use are at 
increased risk of low birth weight, 170 
developmental and educational problems and 
future substance use and addiction. 171 

Controlled Prescription Drugs 

In 2008/ there were an estimated 20,044 
overdose deaths 5 attributable to risky use of 
controlled prescription drugs. The majority of 
these deaths (73.8 percent or 14,800) were 
attributable to the risky use of prescription 
opioids. 172 Overdose deaths from controlled 
prescription drugs have increased significantly 



over recent years and now surpass the number of 
overdose deaths caused by illicit drugs.** 173 



Enough prescription painkillers were prescribed 
in 2010 to medicate every American adult 
around-the-clock for a month. 174 

—Centers for Disease Control and Prevention 



In 2009, there were 224 deaths that involved 
drivers impaired by controlled prescription drugs 
(or an unknown combination of prescription 
drugs, alcohol and other drugs). 175 The risky use 
of controlled prescription drugs was involved in 
an estimated 1,079,683 emergency department 
visits,' f accounting for 39.8 percent of all 
substance-related emergency department visits 
in the U.S. Among prescription drug-related ED 
visits, 73.3 percent involved opioids, stimulants, 
sedatives and barbiturates. 1 * 176 

The risky use of prescription opioids can result 
in a range of consequences from drowsiness and 
constipation to depressed breathing, at high 
doses. Even a large single dose of opioids can 
lead to severe respiratory depression or death. 177 
One study found that individuals with addiction 
involving opioids had significantly higher rates 
of comorbid health conditions, including 
hepatitis, pancreatitis and psychiatric illness than 
those without addiction involving opioids. 178 

At high doses, risky use of prescription 
stimulants can produce anxiety, paranoia, 
seizures 179 and serious cardiovascular 
complications including stroke. 180 Other 
possible adverse effects include slowed growth 
in children, allergic reactions, potentially fatal 
interactions with other drugs §§ and sudden 
death. 181 



* Adjusting for potentially confounding factors such 
as those listed above. 

' Producing what is described in the DSM-IV as a 
Substance-Induced Mental Disorder. 

* Most recent available data that distinguishes 
between illicit and controlled prescription drugs. 

§ Data on other causes of death (e.g., accidents) that 
are attributable to the misuse of controlled 
prescription drugs are not available. 



Specifically, heroin and cocaine. 
^ Measured in terms of patient visits, not individual 
drug reports. 

t+ The remaining prescription drug-related ED visits 
involved antidepressants and antipsychotics (12.3 
percent) or other types of prescription drugs (14.4 
percent). 

§§ Such as MAO inhibitors. 



-61- 



Long-term risky use of benzodiazepines is 
associated with cognitive impairment, other 
adverse effects and a high risk of drug 
interactions, addiction and withdrawal syndrome 
that can be life threatening. 182 Likewise, risky 
use of barbiturates, such as butalbital and 
phenobarbital, can lead to changes in alertness, 
irritability and memory loss. 183 If combined 
with certain medications or alcohol, tranquilizers 
and sedatives can slow both heart rate and 
respiration, which can be fatal. 184 

Taking certain controlled prescription drugs 
during pregnancy, such as alprazolam (Xanax) 
or phenobarbital, may harm the developing 



Chapter IV 

Screening and Early Intervention 



Nearly one-third (31.7 percent) of the U.S. 
population (80.4 million people ages 12 and 
older) engages in substance use that threatens 
their own health or safety or the health and 
safety of others, but does not meet clinical 
diagnostic criteria for addiction. 1 Few of these 
individuals, however, are routinely screened for 
risky use of addictive substances or receive any 
services designed to reduce such use such as 
brief interventions. 2 Of those who do receive 
some form of screening, in most cases it 
involves only one type of substance use- 
tobacco or alcohol— which fails to identify risky 
use of other substances or recognize that 30.6 
percent of risky users who are not addicted 
engage in risky use of more than one substance. 3 

In order to reduce risky use and its far-reaching 
health and social consequences, which may 
include the development of addiction, health 
care practitioners must: 4 

• Understand the risk factors,* how these risks 
vary across the lifespan and how risky use— 
whether or not it progresses to addiction- 
can have devastating outcomes for 
individuals, families and communities; 

• Educate patients, and their families if 
relevant, about these risks and the adverse 
consequences of risky use; 

• Screen for risky use of addictive substances 
and related problems using tools that have 
been proven to be effective; and 

• Provide brief intervention when appropriate. 

Health care practitioners also should conduct 
further assessment if the patient presents with 
signs or symptoms of addiction and treat the 
patient or provide referrals to specialty care if 
needed, as discussed in Chapters V and VI. 



See Chapter II. 



-63- 



Screening and early intervention services should 
be provided in regular health care settings, but 
also can be highly successful when offered in 
other venues to individuals at high risk, 
including students, those in justice programs and 
those in social service settings. To assure that 
these health care services are provided, a range 
of barriers must be addressed, including 
insufficient training of health care and other 
professionals and a lack of trained specialty 
providers to which patients with addiction can 
be referred for treatment; time constraints and 
insufficient financial and workforce resources; 
and screening tools that may fail to detect cases 
of risky use of addictive substances. 

The Need for Patient Education, 
Screening and Intervention 
throughout the Lifespan 

For many health conditions, certain 
developmental periods are associated with 
increased risk of acquiring a disease. 5 
Addiction, in most cases, has its roots in 
adolescence with the initiation of risky use of 
addictive substances, 6 but the onset of risky use 
and addiction can occur at any point in the 
lifespan. Each life phase presents unique 
vulnerabilities that must be recognized, as well 
as the basic risk factors (discussed in Chapter II) 
that may be present at any time in life. 

Childhood and Adolescence 

Adolescence is the critical period for the onset 
of substance use and its consequences,* 7 but 
signs of risk sometimes can be observed much 
earlier. In addition to the overall risks 
associated with substance use, children and 
adolescents with heightened risk of engaging in 
substance use, of experiencing the adverse 
consequences of risky use and of developing 
addiction include: 

• Those with certain genetic predispositions or 
structural or functional brain characteristics 
that make them more susceptible to 
addictive substances; 8 



See Chapter II. 



• Young children whose temperaments' are 
more active, impatient, aggressive and non- 
conforming than their peers, 9 

• Those with behavioral disorders including 
oppositional defiant disorder' and conduct 
disorder/ 10 those who engage in bullying 5 11 
and those who have sleep problems;** 12 and 

• Children who are maltreated, abused or have 
suffered other trauma. 13 

As children age, moving through elementary and 
middle school-a period that coincides with first- 
time exposure to cigarettes and other drugs— they 
are presented with increasing academic and 
social challenges and responsibilities that 
increase their risk of trying addictive substances 
and engaging in substance use. 14 

During adolescence and into early adulthood the 
brain undergoes considerable developmental 
changes, explaining why adolescence is such a 
risky period for the onset of substance use and 
addiction. 15 Hormonal changes that occur 
during adolescence also pose a biological risk 
for substance use in this age group. The surge in 
the female hormone estrogen and the male 
hormone testosterone during puberty is 
associated with risk taking and sensation 



According to the American Academy of Child and 
Adolescent Psychiatry, oppositional defiant disorder 
refers to a pattern of disobedient, hostile and defiant 
behavior directed toward authority figures. Common 
behavioral symptoms include defiance, spitefulness, 
negativity, hostility and verbal aggression. 
* Conduct disorder is diagnosed in youth who exhibit 
enormous difficulty following rules and behaving in a 
socially-acceptable manner. These children may 
bully others, start fights, show aggression toward 
animals, steal or engage in sexually inappropriate 
behavior. 

§ Past-year participation in the following acts: (a) hit 
and pushed or threatened another student, (b) called 
another student mean names, (c) told another student 
you will not like her/him unless she/he did what you 
wanted, (d) made people not like another student, (e) 
told lies or spread rumors about another student, (f) 
not let another student be in your group of friends. 

Mothers' reports of children and teens having 
trouble sleeping and overtiredness. 



-64- 



seeking. The lack of fully developed decision- 
making and impulse-control skills combined 
with the hormonal changes of puberty 
compromise an adolescent's ability to assess 
risks and make them uniquely vulnerable to 
substance use. 16 

Other psychological and social challenges faced 
by adolescents— such as the struggle to develop a 
sense of identity, feeling less satisfied with one's 
appearance and experiencing peer pressure to 
conform— contribute to the risk. 7 

Young Adulthood 

In recent years, researchers have begun to 
recognize the developmental stage of young 
adulthood— often referred to as emerging 
adulthood-as a period of life that is strongly 
associated with risky use. 18 Young adults facing 
heightened risk include: 

• College students-* -while approximately 
two-thirds of college students who engage in 
substance use began to smoke, drink or use 
other drugs in high school or earlier, the 
culture on many college campuses permits 
and promotes risky use rather than curtailing 
it. 19 

• Young adults facing work-related stress or 
instability in living arrangements, social 
relations or academic or career choices. 20 
As marriage and parenthood have become 
delayed, the phase of life devoted to 
academics and career development has 
stretched well into the twenties. Young 
adults may turn to addictive substances to 
relieve these forms of stress and self- 
medicate their anxiety and emotional 
troubles. 21 

Middle and Later Adulthood 

Major life events and transitions increase the 
chances that an individual will engage in risky 
use of addictive substances. 22 Adults may turn 
to risky use when: 



Much of the research conducted on young adults is 
based on college student samples. 



• Coping with the stresses of child rearing, 
balancing a career with family and 
managing a household; 23 

• Facing divorce, caring for an adult family 
member or grandchildren or coping with the 
death of a loved one; 24 

• Struggling with retirement, the loss of 
independent living or financial problems; 25 
or, 

• Coping with an illness, including increasing 
physical ailments such as arthritis or other 
forms of chronic pain. 26 

Middle aged and older adults who engage in 
risky use may be even more vulnerable to the 
health consequences of such use since physical 
tolerance for alcohol and other drugs declines 
with age: the ways in which addictive 
substances are absorbed, distributed, 
metabolized and eliminated in the body change 
as people get older. 27 With regard to alcohol, 
several biological factors account for reduced 
tolerance. The amount of lean body mass 
(muscle and bone) and water in older adults' 
bodies decreases as the amount of fat increases, 
with less water to dilute the alcohol. Reduced 
liver and kidney function slows down the 
metabolism and the elimination of alcohol from 
the body, including the brain. These factors 
allow the effects of alcohol to take hold more 
quickly and depress brain function to a greater 
extent than in younger people, impairing 
physical coordination and cognitive function. 28 

The increasing susceptibility to substance- 
induced neurotoxicity with age is a growing 
concern as the "Boomer" generation, a 
population with higher rates of risky use, ages. 29 
The interaction of prescribed and other drugs 
with alcohol also is of great concern for the 
physical and mental health of middle and older 
adults who are likelier than younger people to 
use prescription and over-the-counter 
medications. 30 



-65- 



Attending to Co-occurring 
Conditions 

Individuals who engage in risky use or who have 
addiction frequently suffer from other co- 
occurring health conditions.* 31 Therefore, any 
attempt to identify risky use of addictive 
substances, evaluate an individual's risk for 
developing addiction or assess a substance 
user's need for intervention or treatment must 
involve identification of co-occurring conditions 
and plans to address them. Being informed of a 
patient's health conditions that might be caused 
or exacerbated by substance use or that might 
cause or exacerbate the patient's addiction will 
help medical professionals determine 
appropriate interventions and provide effective 
care. 32 Similarly, medical professionals treating 
patients with medical conditions that frequently 
co-occur with risky use and addiction- such as 
hypertension, gastritis and injuries— should be 
prompted to screen for risky use of addictive 
substances that may cause or aggravate these 
conditions. 



• Steps patients can take to prevent risky use 
of addictive substances and the onset of 
addiction, e.g., by delaying initiation of 
substance use, following guidelines for the 
safe use of alcohol and of controlled 
prescription medications, being vigilant for 
signs and symptoms of risk and seeking 
professional help at the first sign of trouble. 

Screening 1 

Screening, a staple of public health practice that 
dates back to the 1930s, 34 serves to identify early 
signs of risk for or evidence of a disease or other 
health condition and distinguish between 
individuals who require minimal intervention 
and those who may need more extended 
treatment. 35 It is an effective method of 
preventive care in many medical specialties, and 
risky use of addictive substances is no 
exception. Screening for risky use of addictive 
substances is comparable to offering regularly 
scheduled pap smears or colonoscopies to 
identify cancer indicators. 36 



Patient Education and Motivation 



Educating patients and motivating them to 
reduce their risky use of addictive substances is 
a critical component of preventive care. 33 As 
part of routine medical practice, medical and 
other health professionals should educate their 
patients (and parents of young patients) about: 



• The adverse consequences of risky use and 
the nature of addiction— that it is a disease 
that can be prevented and treated 
effectively; 

• The risk factors for substance use, tailoring 
the information to the patient's age, gender, 
mental health history and other relevant 
medical, social and demographic 
characteristics; 

• Times of increased risk for substance use, 
such as adolescence, key life transitions 
and stressful life experiences; and 



See Chapter II. 



' Despite the distinction between screening and 
assessment tools, the term screening often is used to 
subsume the concept of assessment or 
interchangeably with the term in the clinical and 
research literatures. Nevertheless, Chapter V 
addresses assessments specifically. In addition, 
while there is some overlap between screening or 
assessment procedures used to identify risky use of 
addictive substances and methods used to diagnose a 
clinical addiction, a formal diagnosis of addiction is 
based on the demonstration of specific symptoms 
included in the most recent versions of the Diagnostic 
and Statistical Manual of Mental Disorders (DSM) or 
the International Statistical Classification of Diseases 
(ICD). (See Chapter II.) 



-66- 



It's like taking a blood pressure. You don't just 
take the pressure of patients you suspect of 
having high blood pressure. You take 
everyone 's blood pressure. And, with public 
health screening, you 're typically not shooting 
for a diagnosis, but just an initial measure of a 
patient's level of risk?* 

—Dan Hungerford, DrPH 
Epidemiologist 
National Center for Injury 
Prevention and Control 
Centers for Disease Control and Prevention 



Screening tools typically are brief and easy to 
administer and are to be implemented with a 
relatively broad population to identify 
indications of risk involving smoking, drinking 
or using other drugs. Screening tools typically 
include written or oral questionnaires and, less 
frequently, clinical and laboratory tests. (See 
Appendix H for a description of commonly-used 
screening instruments.) 

An instrument that can be used to screen for 
risky use of all addictive substances— rather than 
separately for each substance-and that makes 
appropriate distinctions for young people and by 
gender has yet to be developed. 

In recent years, attempts have been made to 
develop and validate more simple screening 
tools that can be used in primary care settings. 
For example: 

• A single-item measure of current tobacco 
use* has been validated on adult populations 
for use in research protocols 37 but also can 
be used clinically to determine if a patient is 
a current smoker. 

• The National Institute on Alcohol Abuse and 
Alcoholism (NIAAA) recommends a single- 
question screening test for unhealthy alcohol 



Have you smoked one or more cigarettes in the past 
month? 



use ' to be asked of patients of all ages who 
admit to sometimes drinking alcohol. 39 

• The NIAAA, in collaboration with the 
American Academy of Pediatrics (AAP) 
recently introduced a simple screening tool 
for identifying early signs of risky alcohol 
use in young people ages 9-18. The 
screener begins with two simple questions 
assessing the child's own alcohol use and 
that of his or her friends. Depending on the 
patient's age, positive responses to these 
items would be followed by more in-depth 
questions assessing the level of the patient's 
risk and the provision of appropriate brief 
interventions. 40 

• A recent study found that a single-question 
screening test to identify other drug use in a 
diverse sample of adult primary care patients 
was effective in accurately identifying other 
drug use and may be beneficial in helping 
physicians identify potential medication 
interactions and associated risks of 
prescribing specific medications. 41 

Single-item screening tools can help narrow the 
patient population that requires further 
assessment for the identification of addiction. 42 
However, most instruments focus on specific 
substances rather than the range of addictive 
substances that pose a risk for addiction. The 
National Institute on Drug Abuse (NIDA) has 
begun to move in the direction of a more unified 
look at risky use and addiction with the 
development of a "quick screen" for use in 
general medical settings. The instrument 
actually contains four separate screens and asks 
patients about the frequency of their past-year 
use of each of the following types of substances: 
(1) tobacco, (2) alcohol, 5 (3) prescription drugs 



1 How many times in the past year have you had 5 or 
more drinks in a day (for men)/4 or more drinks in a 
day (for women)? 

* How many times in the past year have you used an 
illegal drug or used a prescription medication for 
nonmedical reasons? 

§ With separate measures of risk for males and 
females— the frequency of having five or more drinks 
in a day for men and four or more drinks in a day for 
women. 



-67- 



(for nonmedical reasons) and (4) illicit drugs. 
Response options for each, on a five-point scale, 
range from never to daily or almost daily. Used 
online, the screening tool tallies the responses to 
generate a score indicating the patient's level of 
risk for each type of substance and the 
recommended level of intervention. It also 
provides additional resources to help 
practitioners intervene appropriately. 43 



Implementing screening and brief intervention 
would be a revolution in 21st century medical 
practice. It would help reduce billions of 
dollars annually in lost productivity, injury and 
social costs associated with risky behaviors. It 
would also encourage those with chronic 
conditions to get the treatment they need. But 
medical practices are unlikely to take action 
without pressure from others who would 
benefit. The question is, when will society 
demand this change?^ 

-John C. Higgins-Biddle, PhD 
Assistant Professor (Retired) 
Community Medicine and Health Care 
University of Connecticut Health Center 



Laboratory Tests 

One approach to screening is to examine 
laboratory values of urine, hair, blood, sweat, 
saliva or carbon monoxide* to determine the 
presence of nicotine, 45 alcohol 46 or other drugs. 4 
Laboratory tests also can be used to look for 
biological symptoms of chronic substance use. 48 
For example, to assess heavy alcohol use, 
doctors can look for elevated levels of the blood 
proteins gamma-glutamyl transferase (GGT) or 
carbohydrate-deficient transferrin (CDT). ' The 
size of red blood cells also increases with 
prolonged heavy alcohol use. 49 The validity of 
testing for these markers as a means of 
identifying risky alcohol use is limited by the 
fact that they are not necessarily unique to risky 
drinkers. 50 For instance, increased GGT also 



* Carbon monoxide breathalyzer tests used to detect 
smoking. 

' Heavy drinkers are defined in this context as 
individuals who consume four or more drinks per 
day. CDT is less accurate at determining heavy 
drinking in women and adolescent populations. 



can be caused by nonalcoholic liver disease. At 
the same time, looking for biological markers is 
more objective than using a patient's self- 
reports, 51 as it is not subject to patients' or 
examiners' biases. 

Unlike tests for other diseases such as diabetes 
and hypertension which can be diagnosed using 
blood sugar or blood pressure measurements, 
there is not a conclusive test that physicians can 
conduct to determine with certainty the presence 
of the disease of addiction. 52 With few 
exceptions,* laboratory tests for nicotine, alcohol 
and other drugs generally inform health care 
providers of whether patients recently 5 have 
been using these substances rather than being 
indicators of chronic use or addiction. 53 

Individuals, groups and organizations may be 
hesitant to agree to laboratory tests for substance 
use for legal, financial or personal reasons. 54 
Widespread use of these tests is costly 55 and, as 
with any other biological testing, the possibility 



1 A liver function test that indicates an elevated level 
of GGT and a complete blood count that indicates 
that the red blood cells have a greater than normal 
mean corpuscular volume (MCV) are evidence of 
chronic heavy alcohol use. 

§ With regard to smoking, high levels of nicotine or 
cotinine indicate active tobacco use or use of nicotine 
replacement therapy (NRT); moderate concentrations 
indicate a smoker who has not had tobacco or 
nicotine for two to three weeks; lower levels may 
indicate a non-smoker who has been exposed to 
environmental tobacco smoke; and very low to non- 
detectible concentrations are found in non-smokers 
who have not been exposed to environmental tobacco 
smoke or a smoker who has not used tobacco or 
nicotine for several weeks. An alcohol test called the 
EtG can detect alcohol up to 80 hours after very 
extensive drinking episodes; however, in 2006, the 
Substance Abuse and Mental Health Services 
Administration (SAMHSA) released an advisory 
saying that the EtG test was not appropriate for 
assessing alcohol use because it is highly sensitive 
and unable to distinguish between alcohol absorbed 
into the body from actual consumption and from 
exposure to many common commercial and 
household products that contain alcohol. Laboratory 
tests can capture instances of other drug use for days 
or weeks after use, depending on the drug. 



-68- 



of errors such as false positives, contamination 
or mislabeling exists. 56 

Given these concerns, biological tests may be 
most useful in verifying conclusions drawn from 
other forms of screening and assessment 
instruments 57 or in specific circumstances where 
any substance use is sanctioned (e.g., use by 
those who are underage, pregnant, have health 
problems, in jobs that require sustained attention 
and vigilance or by juvenile or criminal 
offenders). 58 

Brief Interventions and Treatment 
Referrals 

For those who screen positive for risky use of 
addictive substances that does not meet the 
threshold of clinical addiction, providing brief 
interventions is an effective, low-cost approach 
to reducing risky use. 59 

Brief interventions generally include feedback 
about the extent and effects of patients' 
substance use and recommendations for how 
they might change their behavior. 60 Brief 
interventions often involve motivational 
interviewing techniques f and substance-related 
education; the exact approach may differ 
depending on the target population. 61 Brief 
interventions can be conducted face-to-face, 
over the phone or via computerized feedback to 
patients. 62 They can be performed by health 
professionals after relatively limited training. 63 
Providing brief interventions can save lives and 
reduce a broad range of negative health and 
social consequences including addiction. 



e.g., truck drivers, air traffic controllers, physicians. 
' Motivational interviewing is a patient-centered 
approach to counseling. Counselors attempt to 
initiate behavior change through reflective listening. 
They help patients resolve any ambivalence toward 
reducing their substance use through an empathetic 
discussion of the discrepancies between their values 
and self-image and their current substance use 
behavior. Counselors stress ideas of self-efficacy and 
optimism to their patients. (For a more detailed 
discussion, see Chapter V.) 



For individuals showing signs of addiction, 
providing treatment or referral to specialty care* 
is critical to managing the condition and 
preventing further health and social 
consequences. 64 

Tobacco 

Brief interventions for smoking and other 
tobacco use can be provided by trained health- 
care practitioners and generally occur in clinical 
and primary-care settings. 65 According to 
clinical guidelines, practitioners should provide 
brief interventions based on the "Five A's": 

• Ask. The process begins with inquiries 
about tobacco use, which should be made 
during every visit. 

• Advise. Individuals who smoke should be 
advised in a clear, strong and personalized 
manner to quit. 

• Assess. Practitioners should determine 
whether or not a patient is willing to attempt 
to quit. 

• Assist. If the patient is willing to attempt to 
quit, the practitioner should provide 
assistance by helping patients create a quit 
plan, providing counseling and 
pharmaceutical treatment recommendations, 
offering problem solving and skills training 
and distributing supplementary educational 
materials. One intervention approach is 
known as the "Five R's" where a technique 
is implemented to help motivate patients to 
quit smoking. 66 

• Arrange. Schedule follow-up contact, either 
in person or by phone. 67 



1 See Chapters V and VI. 

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The "Five R's" 

Employing an empathetic counseling style, 
practitioners should: 

• Relevance: Encourage patients to indicate 
why quitting is personally relevant. 

• Risks: Help patients identify the acute, 
long-term and environmental risks they take 
by continuing to smoke. 

• Rewards: Help point out the rewards that 
will come with cessation. 

• Roadblocks: Ask patients to identify any 
roadblocks they may face during their 
attempt to quit and suggest potential 
solutions for each. 

• Repetition: Repeat this process every time 
they see the patient. 



Brief interventions for smoking cessation should 
include a follow-up visit scheduled shortly after 
a patient's quit date. 68 

A more simple approach that is gaining traction 
is to restrict the brief intervention to the first two 
"A's"— Ask and Advise— and then refer the 
patient, usually to a telephone quitline or a 
smoking cessation service, where the other three 
"A's" are performed. 69 A recent review of 
research found that compared to just providing 
advice, physicians who offered assistance in 
quitting to all patients who smoke regardless of 
their stated willingness to quit, could prompt an 
additional 40 percent to 60 percent of smokers to 

70 

try quitting. 

There is some evidence to suggest that shorter 
interventions for smoking cessation may be 
more successful than longer ones, perhaps 
because of the direct, instructional nature of the 
brief intervention. A study of smokers with 
addiction involving alcohol enrolled in an 
addiction treatment program found that 35 
percent of those who received a 10-minute brief 
intervention for tobacco use were abstinent a 
month later compared to only 1 3 percent of 
those who received a more extensive, 50-minute 



In the form of counseling or nicotine replacement 
therapy (see Chapter V). 



motivational interview session. 1 The brief 
advice session directly told patients to quit 
smoking and assisted participants in accessing 
additional information or help to reach that goal. 
In contrast, the more extensive motivational 
interview focused on the advantages and 
disadvantages of smoking, imagining life 
without smoking, providing personalized 
feedback and setting stage-specific goals. 71 

Alcohol and Other Drugs 

Based on screening results, brief interventions 
for alcohol and other drug use begin with 
feedback about the quantity and frequency of a 
patient's substance use, and the potential 
consequences the patient may face as a result. 72 
Brief interventions typically involve the 
counseling technique of motivational 
interviewing.' 1 ' 73 

Health care practitioners trained in providing 
brief intervention services try to help patients 
decide to change their substance use behavior in 
light of the adverse medical and social 
consequences of risky use of addictive 
substances and the many ways in which it may 
conflict with their values and goals, and then 
offer advice on how patients may do so. 74 

The advice for adults 5 may include: 

• Setting a specific limit on consumption; 

• Learning to recognize the antecedents of 
substance use and developing skills to avoid 
use in those situations; 



1 After six months, the abstinence rates of both 
groups had fallen to 13 percent and two percent, 
respectively. 
* See Chapter V. 

§ Given the dangers of substance use during the 
vulnerable period of brain development that 
continues into young adulthood, the advice for 
adolescents and young adults who have not reached 
the legal ages for smoking or drinking alcohol, 
should focus less on limiting risky use and more on 
abstaining from use of all addictive substances. 



-70- 



• Planning ahead to limit drinking and other 
drug use; 

• Pacing one's use; and 

• Learning to cope with the everyday 
problems that may lead to substance use. 75 



Helping patients understand how they can 
change their behavior and encouraging them to 
be optimistic about their ability to do so are 
important components of most brief 
interventions. 77 Interventions delivered in an 
empathetic counseling style are more effective 
than those that rely on confrontation or 
coercion. 78 While brief interventions can avert 
the development of a more serious substance use 
problem, 79 individuals with the disease of 
addiction require more intensive care and should 
be treated or referred to specialty care. 

Effectiveness of Screening and Brief 
Interventions 

The combination of screening and brief 
interventions has shown positive results for 
tobacco, 80 alcohol, 81 illicit drugs and the misuse 



Sometimes referred to as SBI. 



of controlled prescription drugs, across many 
settings and population groups. f 83 

Several large-scale studies have explored the 
effectiveness of screening and brief 
interventions in reducing the consumption of 
addictive substances as well as the serious 
problems and costs that accompany such 
behavior, including visits to emergency 
departments, hospitalization, high-risk injection 
drug use, criminal activity, psychiatric stress 
and depression. 84 One study found that adult 
patients 1 receiving a brief intervention after a 
positive screen by their primary care physicians 
for risky alcohol use experienced 20 percent 
fewer emergency department visits and 37 
percent fewer days of hospitalization than 
patients who did not receive the intervention. 85 
Participants who received screening and brief 
interventions also had significantly fewer arrests 
for alcohol or controlled drug violations (two vs. 
1 1 arrests). 86 

A large-scale study conducted in a broad range 
of medical settings across six states found that 
22.7 percent of the patients in the study screened 
positive for risky alcohol or other drug use or 
addiction. Sixteen percent of the patients who 
were screened received a recommendation for a 
brief intervention, 3.2 percent received a 
recommendation for brief treatment and 3.7 
percent received a referral to specialty 



' It is difficult to compare the effectiveness rates of 
different research trials and programs as many of 
them use restricted populations and vary in the length 
and intensity of the intervention. Despite these 
methodological discrepancies, there are strong data 
showing the effectiveness of screening and brief 
interventions in addressing risky use of addictive 
substances. Studies reporting successful outcomes 
tend to reflect situations where participation was 
voluntary and may not reflect outcomes in a 
population with mandatory participation. 
Furthermore, most of these studies examine the use 
of screening and brief interventions in primary care 
settings as it pertains to alcohol use and not to other 
drug use. 

* Between the ages of 1 8 to 65 who visited a 
physician's office for routine care. 



"FRAMES": 
Key Elements of a Brief Intervention for 
Reducing the Risky Use of 
Alcohol and Other Drugs 76 

A frequently -used brief intervention for the risky 
use of alcohol and other drugs includes six core 
elements identified and verified through 
empirical research that can be summed up by the 
acronym "FRAMES": 

• Feedback regarding personal risk or 
impairment; 

• Responsibility for change; 

• Advice to change; 

• Menu of options for reducing substance use; 

• Empathetic counseling style; and 

• Self-efficacy in terms of ability and 
responsibility to change. 



-71- 



treatment. The study found that brief 
interventions, brief treatments or referrals to 
specialty treatment for those who screened 
positive for risky alcohol and/or illicit drug use 
at baseline were associated with a 38.6 percent 
reduction in rates of heavy alcohol use and a 
67.7 percent reduction in rates of illicit drug use; 
however, it is important to note that this study 
was not a randomized controlled trial. 87 

Screening and brief intervention services also 
have proven effective in increasing entry rates to 
specialized addiction treatment programs for 
patients with addiction 88 and for patients who 
are required to wait to enter standard treatment 
programs. 89 

Tobacco 

When clinics and medical offices require 
screening for tobacco use, tobacco-using 
patients are likelier to achieve smoking 
cessation. This may be because clinics and 
medical offices that have tobacco screening 
systems in place are approximately 1.7 times as 
likely to provide smokers with interventions as 
offices that do not require patients to undergo 
tobacco screening. 90 

A systematic review of 3 1 studies examining the 
effects of smoking interventions provided by 
nurses in hospital settings found that the 
smoking cessation rate of patients who received 
brief interventions was 1.3 times the cessation 



All patients in the study were screened for alcohol 
and other drug use; however, different instruments 
were used in each study site and the thresholds for 
being classified as being a risky substance user varied 
considerably among the sites. Those with moderate 
risk substance use patterns received brief 
interventions such as the FRAMES intervention or 
motivational interviews; those with heavy use 
patterns received brief treatment which consisted of 
brief but more intense interventions such as enhanced 
motivational interviews (MI), motivational 
enhancement therapy (MET) or cognitive behavioral 
therapy (CBT) (see Chapter V for an explanation of 
these therapies); and those who met clinical criteria 
for addiction were referred to specialty treatment. 
There was no control or comparison group in this 
study. 



rate of control group patients. Another large- 
scale study found that smokers who reported that 
they had received a brief smoking cessation 
intervention from their primary care provided 
were more than three times likelier to quit 
smoking than those who did not receive such 
counseling (34.9 percent vs. 10.5 percent among 
patients without co-occurring addiction 
involving alcohol or other drugs or mental health 
disorders and 31.3 percent vs. 6.0 percent among 
those with such co-occurring conditions). 92 

Alcohol 

Screening and brief interventions for risky 
alcohol use have demonstrated efficacy in 
primary care and emergency/trauma settings. 93 
One study, conducted in a primary care setting 
with patients who screened positive for risky 
alcohol use, found a greater decline in the 
number of people who reported binge drinking 5 
among those receiving a brief intervention (from 
85.0 percent at baseline to 61.5 percent three 
years after the first intervention) compared to 
those in the control group (from 86.9 percent at 
baseline to 70.7 percent three years after the first 
intervention). Likewise, there was a greater 
decline in the number of people who reported 
heavy drinking' ' among those receiving the brief 
intervention (from 46.7 percent at baseline to 
23.2 percent three years after the first 
intervention) compared to those in the control 



' The effects of the interventions appear to be 
strongest among cardiac rehabilitation patients. 
* As indicated by a positive response to the question, 
In the past 12 months, did any of the general medical 
providers talk to you about quitting or avoiding 
smoking? 

§ Defined in this study as consuming more than five 
drinks on one occasion during the previous 30 days. 

The brief intervention included a health 
information booklet, two face-to-face, 15-minute 
intervention sessions with a physician spaced one 
month apart and two follow-up calls from nurses 
during the weeks following their interventions; the 
control group only received the information booklet. 
Patients were randomly assigned to one of these two 
conditions. 

^ Consuming more than 20 drinks during the past 
week for men and more than 13 drinks during the 
past week for women. 



-72- 



group (from 49.2 percent at baseline to 34.6 
percent three years after the first intervention). 
The intervention participants also experienced 
55 percent fewer nonfatal motor vehicle crashes 
and 46 percent fewer arrests. 94 Another study 
found that a 30-minute brief intervention was 
associated with significantly fewer at-risk 
patients being arrested for driving under the 
influence of alcohol during the next three years 
(1 1.3 percent of brief intervention patients had a 
DUI arrest vs. 21.9 percent of control group 
patients). 95 

A systematic review of emergency department- 
based screening and brief intervention programs 
found that 82 percent of the studies included in 
the review demonstrated a positive effect. ' 96 
Even in non-emergency cases and cases 
seemingly unrelated to substance use (e.g., 
general surgery and anesthesia consults), 
routinely screening all pre-surgical patients for 
risky use and addiction can prevent 
complications from surgery, and brief 
interventions or referral to treatment can prevent 
the presenting condition from worsening. 97 
Brief interventions conducted in trauma centers 
for patients who engage in risky alcohol use 
have been associated with a 47 percent reduction 
in re-injuries requiring emergency department or 
trauma center admission and a 48 percent 
reduction in re-injuries requiring hospital 
admission. 98 Brief interventions with follow-up 
are more effective than single-contact 

qq . . . 

interventions: a review comparing multi- 
session and single-session brief alcohol 
interventions found that those who received 
multi-session brief interventions reported a 13 to 
34 percent greater reduction in the average 
number of drinks per week after six to 12 



months than those receiving single-session brief 
interventions.* 100 

Other Drugs 

Although the research on screening and brief 
interventions for other drug use is quite limited 
and therefore data supporting these services is 
scarcer than in relation to tobacco and risky 
alcohol use, 101 the available research suggests 
that screening and brief interventions can reduce 
other drug use among patients in primary care 
facilities, emergency departments, trauma 
centers and other hospital units. 102 In one study 
conducted at six health care sites across the 
country, patients who screened positive for drug 
use (other than tobacco or alcohol) received 
screening and brief interventions, brief treatment 
or referrals to treatment based on the severity of 
their drug use. Six months after receiving these 
interventions, the percentage of patients 
reporting past month marijuana, cocaine, 
methamphetamine, heroin or other drug use- 
including the misuse of prescription sedatives 
and opioids as well as hallucinogens and 
inhalants-decreased significantly. 103 However, 
this study did not contain a control condition so 
the extent to which substance use would have 
decreased without these interventions cannot be 
determined. (Figure 4.A) 

Patients in the study reported significant 
increases in health status (from fair to good) and 
employment (from 31.3 percent to 36.1 percent) 
at the six-month follow-up as well. There also 
were significant decreases in the percentage of 
patients reporting past-month emotional 
problems (from 25.6 percent to 17.6 percent), 
arrests (from 12.2 percent to 4.4 percent) and 
homelessness (from 1 1.8 percent to 6.4 
percent). 104 



Specifically, those who have a BAC > 80 mg/dL or 
a score > 8 on the AUDIT screening instrument. 
* Ninety percent showed a decrease in alcohol 
consumption, 13 percent showed a decrease in 
emergency department visits and hospitalizations, 13 
percent showed a decrease in negative social 
consequences and 13 percent showed an increase in 
referrals for follow-up and/or treatment. 



1 Ranges rather than single values are cited because 
the figures come from a meta-analysis comparing 
results from multiple studies. 



-73- 



Figure 4. A 

Pre- and Post-Past Month Use of Specific Drugs among 
Patients* Exposed to Screening and Interventions 



65 



37 



21 



ft 



12 



• Baseline 

1 6 Month Follow Up 
18 



10 










3 




5 











Marijuana 



Cocaine 



Methamphetamine 



Heroin 



Other Drugs 



* Who report any illicit drug use at baseline. 

Source: Madras, B.K., Compton, W.M., Avula, D., Stegbauer, T, Stein, J.B., 
Clark, H.W. (2009). 



Another study found that a screening and brief 
intervention program* for heroin and cocaine 
users implemented during a routine medical visit 
was related to greater abstinence among 
intervention versus control participants from 
cocaine use (22.3 percent vs. 16.9 percent) and 
heroin use (40.2 percent vs. 30.6 percent) six 
months following the intervention. 



105 



Brief interventions also can reduce regular 
amphetamine use. Six months after screening 
positive for amphetamine use, individuals who 
received brief interventions f were significantly 
likelier to be abstinent than users who received 
only self-help booklets. Amphetamine users 
who received brief interventions also showed 
decreased psychiatric distress scores and 
depression levels. 106 



Consisting of toxicological and questionnaire 
screening during routine care at an inner-city 
teaching hospital, as well as brief motivational 
interviews, active referrals, a list of treatment 
providers and a follow-up booster phone call. 
' In this study, each participant had four 45- to 60- 
minute individual therapy sessions guided by a 
therapist manual and a self-help booklet. The 
sessions included role-play and take-home exercises, 
concentrating on coping strategies and relapse 
prevention. The first session focused on increasing 
motivation to reduce drug use, the second on 
reducing cravings through muscle relaxation and self 
talk, the third on controlling thoughts about drug use 
and the fourth on coping with lapses and developing 
skills to use in high-risk situations. 



Implementing 
Screening and 
Brief 

Interventions in 
Health Care and 
Other Settings 

While screening and 
brief interventions can 
be provided in a broad 
range of venues, 107 
health care settings may 
be the most effective. 
Physicians and other 
health care providers, including dental 
professionals, nurses and pharmacists, typically 
are a consistent, trusted and influential presence 
in the lives of children and adults and their 
professional position grants them the authority 
and credibility to deliver effective, evidence- 
based interventions to patients at risk for 
complications related to their substance use, 
including addiction. Part of the success of 
incorporating these services for risky use of 
addictive substances into standard medical 
practice is that people tend to be more receptive 
to health messages once they are in a health care 
setting. Patients view additional screening, 
information, brief intervention or referral to 
treatment as part of the health care they sought 
initially. 108 The use of technology to assist in 
the completion of screening and brief 
interventions holds promise for helping to 
integrate these practices into routine health care 
delivery. 109 

Primary Care 

About 80 percent of Americans 4 visited at least 
one physician or other health care professional 
in the past year, 110 and the American Society of 
Addiction Medicine (ASAM) estimates that 
more than two-thirds of people with addiction 
are in contact with a primary or emergency care 
physician about twice a year. 1 1 1 Integrating 
screening and brief interventions into routine 
medical check-ups can be an effective way of 



Ages 1 8 and older. 



-74- 



identifying smoking, risky drinking and other 
drug use before negative consequences occur, 
including the development of addiction. 112 



Although the most promising research findings 
regarding the benefits of implementing these 
services in health care and other settings have 
been found in primary care settings, clinical 
trials are lacking in this area. 114 Given the 
strong scientific evidence to date supporting the 
use of screening and brief interventions, 
particularly for smoking and risky alcohol use, 
several national medical societies already have 
endorsed this approach, including: 

• The American Society of Addiction 
Medicine (ASAM) has identified screening 
and brief interventions as an effective 
method for catching substance-related 
problems early and preventing the 
development of addiction; ASAM 
encourages medical and insurance 
professionals to redesign their primary care 
and funding practices to accommodate these 
programs. 115 

• The American Academy of Family 
Physicians recommends that adults, 
including pregnant women, be screened for 
tobacco use and provided with cessation 
interventions or brief counseling and that 
screening and brief interventions for alcohol 
use be used in health care settings as well. 116 



• The American College of Obstetricians and 
Gynecologists' Committee on Ethics 
declared that obstetrician-gynecologists 
have an ethical obligation to conduct 
universal screening, brief intervention and 
referral to treatment for their patients. 117 

• The American Dental Association advises 
dentists to address the issue of risky use and 
addiction with patients and refer them to 
appropriate addiction treatment if needed. 118 

Even the United States Preventive Services Task 
Force (USPSTF), which is constrained by 
available medical evidence, has recommended 
screening and brief intervention for risky alcohol 
use for all adults in primary care settings,* 119 
and that all adults, including pregnant women, 
be screened for tobacco use and receive 
appropriate cessation counseling/ 120 And, the 
National Quality Forum has endorsed screening 
and brief interventions for tobacco and alcohol 
use in general health and mental health-care 

1 21 

settings. 

Adolescent Health Care. Screening the 
adolescent population for substance use may be 
the single most effective preventive step that can 
be taken to address the problem of risky use and 



The USPSTF recommends this service with a B 
rating, indicating that the net benefits of the 
intervention outweigh any potential harms. 
' The USPSTF recommends this service with an A 
rating, indicating that the net benefits of the 
intervention substantially outweigh the harms; for 
pregnant women, the Task Force recommends that 
the counseling services be tailored to pregnancy. As 
a result of limited research on the topic, the USPSTF 
concluded that there currently is insufficient clinical 
evidence to determine the balance of benefits and 
harms of routine (asymptomatic) screening or 
interventions for tobacco or alcohol use among 
adolescents or for screening individuals for illicit 
drug use in primary care practice settings. A recent 
report by the USPSTF, however, identified 1 1 high- 
priority areas in preventive medicine that have 
critical evidence gaps that, if addressed through 
targeted research, are likely to result in 
recommendations for practice. Among these 1 1 
high-priority areas are screening and providing 
counseling for adolescent alcohol use and screening 
all individuals for illicit drug use. 



The 2010 National Drug Control 
Strategy Recommends: 

• Increasing health care providers' 
knowledge and use of screening and brief 
intervention techniques through enhanced 
medical and nursing school educational 
programs; 

• Increasing screening and early intervention 
for substance use in all health care settings; 
and 

• Increased reimbursement for screening and 
brief interventions in primary care. 113 



-75- 



addiction in this country since the consequences 
of risky use of addictive substances among 
adolescents are so profound and individuals with 
addiction typically began engaging in risky use 
in adolescence. 122 



The primary care office is a key setting for 
adolescent screening and brief intervention 
related to substance use; using computer 
technology to achieve these ends meets the needs 
of both patients and physicians by making the 
process more efficient and easier for physicians, 
producing more honest responses from patients, 
and increasing both providers' and patients' 
satisfaction with the encounter. 126 

--John R. Knight, MD 
Director, 

Center for Adolescent Substance Abuse Research 
Associate Professor of Pediatrics, 
Harvard Medical School 
Senior Associate in Medicine, 
Associate in Psychiatry, 
Children's Hospital Boston 



> Be knowledgeable about addiction and 
skilled in recognizing the risk factors for 
substance use among young people; 

> Screen all patients for substance use at 
annual medical examinations and, if 
possible, at other medical visits as well 
using screening methods that are 
validated, nonjudgmental and that 
protect confidentiality; 

> Provide brief interventions and refer 
patients, when necessary, to treatment or 
specialty care; 

> Consider and address co-occurring 
disorders; and 

> Promote substance use prevention 
programs and media responsibility with 
regard to depictions of substance use. 127 

Emergency and Trauma Care 



The U.S. Public Health Service's clinical 
practice guideline for tobacco use and 
dependence recommends that clinicians ask 
adolescent patients about their tobacco use and 
provide them with brief interventions to aid in 
quitting. 123 

Professional medical associations such as the 
American Medical Association (AMA) and the 
American Academy of Pediatrics (AAP) support 
screening adolescent patients for substance use, 
and promote the use of screening and brief 
intervention techniques among their 

124 

constituents: 

• The AMA' s Guidelines for Adolescent 
Preventive Services recommend that 
physicians ask all adolescents annually 
about their use of tobacco, alcohol and other 
drugs, including over-the-counter drugs, 
controlled prescription drugs and anabolic 
steroids. 125 

• The American Academy of Pediatrics 
(AAP) encourages pediatricians to: 



Emergency Departments (EDs) and trauma 
centers are particularly critical venues for 
screening and brief intervention since so many 
emergency and trauma cases involve risky 
substance use. One study found that up to 3 1 
percent of all patients treated in hospital EDs 
who were screened for risky alcohol use f had a 
positive result. + 128 Many trauma patients meet 
criteria for addiction; a study of seriously injured 
trauma patients shows that 24.1 percent of them 
met diagnostic criteria for alcohol dependence 
and 17.7 percent for other drug dependence} 29 
Further, substance-using individuals frequently 
rely on EDs for much of their health-care 



Fifty percent of severely injured trauma patients and 
22 percent of minor trauma patients receive their 
injuries under the influence of alcohol. 
' Based on the CAGE questionnaire. 
* Fhis most likely is a conservative estimate since 
many EDs do not screen for alcohol or other drug use 
because of insurance laws (i.e., the Uniform Accident 
and Sickness Policy Provision Law-UPPL) restricting 
payment if the reason for admission was substance 
related. 



-76- 



EDs and trauma centers are ideal settings for the 
"teachable moment" that is thought to be one of 
the key components of the positive impact of a 
brief intervention. 131 Most individuals who 
experience substance-related accidents and 
injuries do not meet clinical criteria for 
addiction 132 but are excellent candidates for brief 
interventions. One study of young adults 
admitted to a hospital emergency department 
found that those who were alcohol-involved 
and who received a brief motivational 
intervention followed by two telephone booster 
sessions showed greater reductions in alcohol 
use than those who just received one to three 
minutes of feedback, in which they were 
provided information about how much they 
drink, what happens when they drink and how 
their alcohol intake compares to their peers (a 
reduction of up to 53 percent vs. 18 percent). 133 



ED and trauma physicians were some of the first 
to recommend the adoption of screening and 
brief interventions; 134 their focus to date has 
been on excessive alcohol use which is the 
leading risk factor for injury: 135 

• The American College of Emergency 
Physicians recommends screening and brief 
interventions for alcohol use. 136 

• The American College of Surgeons 
Committee on Trauma requires that Level I 
and Level II trauma centers have a 
mechanism in place to identify patients who 



Screened positive for alcohol use, reported drinking 
in the six hours before their accident or had a history 
of risky drinking (as determined by their AUDIT 
score). 



engage in risky alcohol use and Level I 
Centers must have a mechanism in place to 
intervene with these patients. 1 " 137 

An important point of access to the health care 
system for adolescents is through the ED; 
approximately 12.7 percent of substance-related 
ED visits are made by individuals ages 12 to 20 
years old (5.7 percent by those ages 12 to 17 and 
7.0 percent by those ages 18 to 20). 138 
Interventions conducted in the ED may reach 
adolescents who do not attend school regularly 
or who do not have a primary care physician. 139 

Health Care for Pregnant Women* 

Given the considerable impact of substance use 
on reproductive health and pregnancy, women 
(especially those who are pregnant or of 
reproductive age) are an ideal target for 
screening and brief intervention services. 141 
Because there is no universally safe level of 
substance use during pregnancy, any use should 
be screened for and addressed. The American 
College of Obstetricians and Gynecologists 
recommends that because of these risks, all 
women— regardless of present pregnancy status- 
should be screened for alcohol use at least yearly 
and provided with intervention and referral 
services if necessary. 142 

One study found that pregnant smokers who 
received brief counseling and behavioral 
interventions in a public maternity hospital had a 
higher rate of smoking abstinence (33.3 percent) 
than pregnant smokers who received usual care 
(8.3 percent). 143 Another study found that 
pregnant smokers in community health centers 
who received brief interventions were more 
likely to be abstinent by the end of their 
pregnancy than women receiving usual prenatal 
care (past-month abstinence rate of 26 percent 
vs. 12 percent). However, in this study, the 
higher rates of smoking abstinence following a 



1 The focus in this area primarily has been on alcohol 
rather than tobacco or other drugs. 
* Research on screening and brief interventions for 
pregnant women focuses primarily on tobacco and 
alcohol use. No studies of the use of such services in 
pregnant women who use other drugs were found. 



Research [related to screening and brief 
intervention] began in the ED. The earliest 
study— conducted in 1957— was a controlled trial 
with 200 dependent drinkers at Massachusetts 
General Hospital. Patients who had a 
nonjudgmental, respectful conversation inviting 
them to attend an outpatient program were more 
likely than other patients to complete one 
appointment (65.0 percent vs. 5.4 percent) and 
five appointments (42.0 percent vs. 1.1 
percent). 140 



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brief intervention disappeared at three and six- 
month post-partum follow-ups, 144 indicating a 
need for more intensive treatment services. 

Screening and brief interventions in prenatal 
care settings have been found to reduce alcohol 
use significantly, 145 as well as the chances of 
low birth-weight deliveries. 146 Brief 
interventions for alcohol use among pregnant 
women are effective even when provided in a 
community setting by non-medical 
professionals. 147 Programs that include spouses 
and partners are particularly effective. 148 

Mental Health Care 

Despite the high rate of co-occurring addiction 
and mental health disorders, 149 screening and 
brief interventions for risky substance use are 
not common practice in mental health settings 
and are not standard practice in the field of 
psychiatry. 150 

There are effective tools for screening patients 
with mental health conditions in mental health 
settings for risky use of addictive substances 151 
and there is evidence that interventions can be 
effective in addressing such use among those 
with psychiatric conditions. 152 For example, a 
study evaluating the effectiveness of a screening 
and brief intervention program in a primary 
health and mental health care setting at a 
university found that six weeks after receiving 
the intervention, participants decreased their 
alcohol use.* 153 

Dental Care 

Dental professionals can play a unique role in 
detecting substance use among their patients, 
providing brief interventions and referring 
patients to treatment. 154 Risky use and addiction 
have a significant impact on multiple 
components of dentistry including patients' oral 



* Including the average number of drinks consumed 
per week over the past 30 days, the highest number of 
drinks consumed on one occasion in the past 30 days 
and the number of times in the preceding two weeks 
participants had consumed five or more drinks on one 
occasion. 



health 155 and the safety of common treatments 
and interventions including the prescription of 
controlled medications such as opioid pain 
relievers. 156 The fact that dental health 
maintenance and treatment require routine and 
often repeated visits makes dental professionals 
a consistent and potentially influential presence 
in the lives of people who engage in risky use of 
addictive substances. 157 Dental patients are 
receptive to their dentists' involvement in the 
prevention and treatment of risky use and 
addiction. A 2005 survey of patients visiting an 
emergency dental clinic found that 80 percent 
believed dentists should ask their patients how 
much alcohol they drink; 90 percent believed 
that dentists should warn patients to drink less 
or quit if it is affecting their oral health. 158 

Pharmacies 

The responsibilities of pharmacists with regard 
to the prevention and early intervention of risky 
use and addiction extend to administering 
prescription medications; pharmacists are the 
best source of information regarding the safe and 
effective use of medications and the adverse 
effects that arise from their misuse. They also 
can be instrumental in controlling the diversion 
of prescription medications for misuse by 
monitoring the number of prescriptions filled by 
a patient, looking for false or altered prescription 
forms 159 and recognizing when a patient is 
"doctor shopping"' or in need of treatment. 160 

High School, College and University 
Settings 

Screening and brief intervention programs 
reduce risky use of addictive substances among 
students by changing their attitudes, beliefs and 
expectations regarding tobacco, alcohol and 
other drug use. 161 

School health programs, in collaboration with 
primary care providers, are important 
opportunities for screening adolescents and 
young adults for substance use, primarily 



1 The practice of patients visiting various health care 
providers to obtain multiple prescriptions for the 
drugs they misuse. 



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because young people spend a majority of their 
time in school. Few schools, however, take 
advantage of this opportunity. 162 A CASA 
Columbia survey of school personnel, conducted 
for its 2011 report, Adolescent Substance Use: 
America 's #1 Public Health Problem, found that 
only 7.4 percent reported that their schools 
screen all students for signs of risky alcohol or 
other drug use; 9.0 percent of high school 
teachers reported that their schools screen 
particular groups of high-risk students for signs 
of risky alcohol or other drug use. 163 

The college setting also is ideal for intervening 
with young people at risk via screening and brief 
interventions because of the high rates of 
substance use in the college population; an 
estimated 67.2 percent are risky users or have 
addiction.' 169 To date, the majority of the 
screening- and intervention-related research 
among college students has focused on alcohol, 
most likely because alcohol typically is the 
substance most likely to be used by college 
students. 170 Screening and brief interventions 
have proven successful in reducing risky alcohol 
use and its consequences in this population. 171 
The Department of Education recommends the 
implementation of screening and brief 
intervention programs in all college health 

1 7? 

centers. 



Brief Alcohol Screening and Intervention 
of College Students (BASICS) Program 

The BASICS program targets risky drinkers 
(defined as those who drink heavily and are at 
risk for or already have experienced problems 
related to alcohol use) between the ages of 18 
and 25. 164 Students are identified for 
participation in the programs through screening 
or through referral from medical, housing or 
disciplinary services. 165 The program consists of 
two one -hour interviews and a brief online 
assessment survey about drinking habits and 
history, as well as beliefs and attitudes, while 
giving instructions for monitoring one's own 
drinking between interviews. In the second 
interview, students receive personalized face-to- 
face feedback about their alcohol use compared 
with peer norms, consequences of and risk 
factors for drinking and strategies for reducing 
alcohol use and related problems. 166 The 
BASICS program has proven to be effective and 
cost-effective. 167 In one study, students who 
received the BASICS intervention as college 
freshmen were more likely than risky drinkers 
who did not participate in the intervention to 
have reduced their alcohol consumption four 
years later (67 percent vs. 55 percent). 168 



Justice Settings 

Juvenile justice programs and facilities are ideal 
venues for screening and brief interventions; 
CASA Columbia's 2004 report, Criminal 
Neglect Substance Abuse, Juvenile Justice and 
The Children Left Behind, found that four of 
every five children and adolescents in the 
juvenile justice system are substance 
involved.* 173 Unfortunately, jurisdictions 
typically do not provide adequate screening or 
brief intervention services 174 even though there 
are several screening tools that have been 
validated for use with juvenile offenders. 175 



Of enrolled college students, ages 18-22. 
1 43.9 percent are risky users but do not have 
addiction and 23.3 percent have addiction, i.e., meet 
clinical diagnostic criteria for past month nicotine 
dependence and/or past year alcohol and/or other 
drug abuse or dependence. 



x Under the influence of alcohol or other drugs while 
committing their crime, test positive for drugs, are 
arrested for committing an alcohol or other drug 
offense, admit to having a substance use problem or 
share some combination of these characteristics. 



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One national study of juvenile residential 
facilities found that 1 5 percent of the facilities 
that reported information about evaluating 
residents for substance-related issues indicated 
that they did not screen at all, 20 percent 
reported that they screened some youth and 64 
percent reported that they screened all youth; 4 1 
percent reported using a standardized screening 
instrument. 7 Even those facilities that screen 
youth and use a standardized screening 
instrument do not necessarily provide 
appropriate interventions or treatment based on 
screening findings. 177 

The criminal justice system includes even higher 
concentrations of individuals whose crimes are 
linked to their use of alcohol and/or other drugs. 
CASA Columbia's 2010 report on substance use 
in this population, Behind Bars II: Substance 
Abuse and America 's Prison Population, found 
that 84.8 percent of inmates in America are 
substance involved. 1 178 Screening can be used 
to identify those in need of intervention and to 
make appropriate referrals to treatment, which 
ultimately can help to reduce crime and prison 
overcrowding and save taxpayer money. 179 

Despite abundant evidence of the efficacy of 
screening and brief interventions, 180 
standardized screening and interventions are not 
implemented regularly injustice settings. 181 
Although inmates are guaranteed the right to 
medical care, 182 they routinely are denied access 
to appropriate screening, intervention and 
treatment services for the disease of addiction. 183 

The Workplace 

The majority of people ages 18 and older who 
meet clinical criteria for addiction (63.8 percent) 



Of the 2,658 facilities in the final sample, 2,128 
reported information about screening. 
1 Substance-involved inmates are those who either 
had a history of using illicit drugs regularly; met 
clinical criteria for addiction; were under the 
influence of alcohol or other drugs when they 
committed their crime; had a history of alcohol 
treatment; were incarcerated for a drug law violation; 
committed their offense to get money to buy drugs; 
were incarcerated for an alcohol law violation; or had 
some combination of these characteristics. 



or who engage in risky use but do not have 
addiction (73.0 percent) are employed full or 
part time; 184 individuals who engage in risky 
substance use or are addicted have higher rates 
of absenteeism, decreased work productivity and 
higher health care costs. 185 

If approached as a health issue, the workplace is 
an ideal venue for offering confidential 
screening, brief interventions and treatment 
referrals. Workplaces increasingly rely on 
Employee Assistance Programs (EAPs) 186 — 
confidential counseling programs for employees 
that offer assistance with health or other 
problems that can adversely affect job 
performance. 187 One recent survey of human 
resource professionals found that 60 percent 
reported that their organizations offered 
employee wellness programs and 42 percent had 
health screening programs. 188 Only recently, 
however, have there been attempts to utilize 
EAPs and similar workplace programs to 
provide screening and brief intervention services 
to employees. 189 

Researchers have demonstrated that providing 
these services to employees who contact an EAP 
program for assistance can be effective at 
identifying risky use and addiction. 190 Several 
pilot studies 3 - have demonstrated the 
effectiveness of identifying risky drinking 5 
among employees via EAP services and of 
having those who were identified agree to 
follow-up counseling. 191 According to a 
national employer survey, however, only 29 
percent of employers offer screening to their 
employees for risky alcohol use and 60 percent 
of that group provide brief interventions. 192 
Comparable data on the proportion of employers 
that screen or provide interventions for 
employees who smoke or use other drugs are not 
available. 



J Conducted in partnership with Aetna and 

OptumHealth. 

§ Using the AUDIT. 

** Of the employers that provide screening, most 
reported using the EAP, human resources, 
occupational health and safety and educational 
outreach programs to conduct the screening. 



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Unfortunately, much workplace screening takes 
the form of drug testing and is used for 
compliance purposes. In this light, it frequently 
is viewed as infringing on workers' privacy; 193 
workers may worry about the confidentiality of 
their test results and whether they will be used to 
deny employment or to impose other forms of 
discrimination. 194 The drug- testing process can 
be costly as well. 195 In conducting workplace 
drug testing, the American Society of Addiction 
Medicine (ASAM) recommends that a positive 
drug test be used only as evidence that substance 
use occurred, not as evidence of functional 
impairment or addiction; the interpretation of 
drug test results should include the use of a 
credentialed Medical Review Officer; and 
controlled prescription medications should be 
included in the screening. 196 

Government-Funded Social Service 
Systems 

Government agencies can play an important role 
in providing screening and brief interventions to 
a range of clients including those receiving 
housing, welfare and child protection, services 
for the elderly, and in HIV and STD clinics. 197 
Government- funded social service systems can 
identify substance use risk in individuals 
participating in their programs and provide 
interventions, treatments or referrals to specialty 
care when addiction is identified. 

A significant proportion of individuals who 
participate in government programs have many 
risk factors for substance use and addiction and 
can benefit from screening and brief intervention 
services. Identifying individuals at risk and 
providing effective interventions for those in 
need may help to reduce their risk of further 
substance use, job loss, domestic violence and 
other crime and, ultimately, can lead to cost- 
savings through decreased demand for 
government services. 198 Despite the logic of this 
approach, there is little research on the 
effectiveness of screening and brief 
interventions in these populations and, instead of 
implementing these services, some states are 
now imposing or considering drug testing as a 
precondition for cash assistance and other 



services and a basis for denying both program 
eligibility and needed medical care.* 199 

Barriers to Effective 
Implementation of Screening and 
Brief Interventions 

The failure of our health care providers, schools, 
employers, justice programs and social service 
programs to implement effective screening, brief 
interventions and treatment referrals for those 
who engage in risky use of addictive substances 
represents a tremendous missed opportunity to 
help countless Americans avoid the far-reaching 
consequences of risky use and the disease of 
addiction. A significant barrier to change is the 
fact that services aimed at preventing and 
addressing risky use and addiction traditionally 
have not been paid for by health insurance plans; 
as a result, there are few incentives for health 
professionals to make them a priority in the care 
of their patients. To close the gap in needed 
services, specific barriers in addition to 
insufficient funding must be addressed, 
including insufficient training of health care and 
other professionals and a lack of specialty care 
providers; competing priorities and insufficient 
resources; and inadequate screening tools. 200 

Insufficient Training 

Many physicians and other health professionals 
do not screen their patients for risky use of 
addictive substances, provide early interventions 
or treat or refer for specialty care, or they do so 
inadequately because they simply have not been 
properly trained. 1 Education about risky use and 
the disease of addiction, their impact on a 
patient's health and other medical conditions, 
and how to implement screening, interventions 
and treatment is not sufficiently integrated into 
medical education or residency training 
programs. 201 Among those programs that do 
address substance use and addiction, many have 
shortcomings in the curriculum such as 
insufficient instruction, limited number of 



The Constitutionality of these policies is being 
tested in the courts. 
1 See Chapters IX and X. 



-81- 



courses and limited time spent in courses on the 
topic of addiction. 202 

Inadequate training in risky use and addiction 
means that many physicians do not recognize 
these conditions in their patients, do not believe 
that substance-related interventions are 
effective, 203 are unaware of what do with a 
patient who screens positive for risky use or 
addiction or are uninformed about effective 
resources to which they could refer patients in 
need of more in-depth assessment or of specialty 
treatment. 204 

Most schools lack employees or consulting 
personnel with the necessary training and 
resources for identifying students who engage in 
risky use of addictive substances and attaining 
appropriate intervention services for those 
students who need them. 205 CASA Columbia's 
survey of school personnel conducted for its 
201 1 report, Adolescent Substance Use: 
America 's #1 Public Health Problem, found that 
three-fourths of teachers are unable to identify a 
professional in their schools who would be able 
to help students with a substance use problem. 
Only 26.9 percent of teachers report that their 
schools train educators and other school staff to 
identify and respond to student substance use. 206 
Other national surveys likewise find that high 
school counselors and school psychologists 
generally report low competence in providing 
direct substance-related intervention services to 
students and a lack of relevant opportunities to 
become trained in doing so. 207 Most schools 
have not set up partnerships with health care 
providers trained in conducting screening or 
early interventions to refer students who engage 
in risky use nor do they have links to appropriate 
treatment programs to which they refer students 
with addiction. 208 

CASA Columbia's 1999 report, No Safe Haven: 
Children of Substance-Abusing Parents, found 
that insufficient training among most child 
welfare workers and family court judges greatly 
contributes to the lack of effective screening 
practices in the child welfare system. 209 CASA 
Columbia's research, published in its 2010 
report Behind Bars II: Substance Abuse and 
America's Prison Population, found that 



probation and parole officers in the justice 
system need to be better trained as well. 210 

A related barrier to screening for risky use of 
addictive substances and providing brief 
interventions is the lack of effective and 
appropriate specialty treatment services 
available for referral when addiction is 
identified. 211 Although having more trained 
addiction physician specialists is critical to 
providing care for those with severe forms of the 
disease, the lack of such specialty providers is 
not a legitimate barrier to providing screening 
and brief interventions. Neither is it a legitimate 
reason for general health care professionals to be 
unprepared to provide addiction treatment that 
does not require specialty care. These services 
are designed to be provided in non-specialty care 
settings, along with some forms of assessment 
and treatment (see Chapter V). The real barrier 
in this case remains the lack of knowledge about 
risky use and addiction and insufficient training 
in addressing these issues among health 
professionals. 

Competing Priorities/Insufficient 
Resources 

Lack of time and resources in the face of 
competing priorities is one of the most 
prominent barriers to implementation of 
screening and brief interventions among health 

213 

professionals, school personnel and 

214 

government agencies. 

Because the general model in medicine today 
(which is reflected or driven by insurance 
reimbursement structures) is procedure-oriented 
and reactive more than preventive, and because 
insurance coverage for screening and brief 
interventions for substance use has been rare,* 
these services end up falling low on most 
physicians' lists of competing priorities for their 
time and attention. 215 

Schools and government agencies that 
administer justice programs or provide social 
services also face competing priorities and 
financial constraints that serve as barriers to 



See Chapter VIII. 



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their implementation of screening and brief 
intervention services. 216 Too often, state 
policymakers or administrators of these 
programs fail to understand how risky use and 
addiction impede progress in achieving their 
organizational goals. 

The priorities of protecting patient 
confidentiality and maintaining an amicable and 
trusting doctor-patient relationship also may 
impede health professionals' implementation of 
these practices. 217 While existing federal 
regulations* protect the privacy of patients 
receiving addiction-related services in settings 
that are federally assisted and that are primary 
providers of these services, the regulations do 
not apply to other service venues. 218 These 
ambiguous rules serve as a disincentive to health 
professionals to offer screening and brief 
intervention services and an incentive to keep 
substance-related services divorced from 
mainstream medicine. 219 

Inadequate Screening Tools 

Another barrier to the effective implementation 
of screening and brief intervention has been that 
widely-used screening tools do not adequately 
identify the full range of incidences of risky 
use. 1 These tools also do not follow consistent 
standards nor are they designed to be tailored to 
the unique patterns, symptoms and 
consequences of substance use of different age 
groups, genders, races/ethnicities and cultures or 
of individuals with co-occurring conditions, for 
whom a lower level of use may constitute risk 
relative to an average respondent. 1 220 Further, 
most screening instruments focus on specific 
substances independently rather than identifying 
risky use of all addictive substances or risk for 
addiction as a unified disease. Reliance on 



Known as 42 CFR, Part 2 (Confidentiality of 
Alcohol and Drug Abuse Patient Records). 
1 See Appendix H. 

* For example, any use of addictive substances by 
children, adolescents or pregnant women constitutes 
risky use; risky alcohol use is defined differently for 
women vs. men; and substance use by some 
individuals with co-occurring health conditions poses 
extreme risks even at levels that may be considered 
relatively safe among those without such conditions. 



instruments that screen only for one type of 
substance increases the likelihood that risky use 
will not be adequately detected or that 
interventions will fail to reduce risky use across 
the board. 

Only a few screening instruments have 
undergone rigorous scientific examination to 
determine their reliability, validity, sensitivity 
and specificity-key elements determining the 
effectiveness of such instruments. 5 221 Rather 
than using objective and standardized measures 
of risky use and risk for addiction, many of the 
more commonly-used screening instruments 
determine risk by relying on respondents' 
subjective reports of their own reactions to their 
use of addictive substances and the reactions of 
those around them, or their experiences of 
adverse social and health consequences 
associated with such use. For example, while 
risky alcohol use commonly is defined simply as 
drinking in excess of the established dietary 
guidelines of no more than one drink per day for 
women and two drinks per day for men, the 
CAGE Questionnaire simply asks four items 
related to the respondent's alcohol use--(l) Have 
you ever felt you should Cut down on your 
drinking? (2) Have people Annoyed you by 
criticizing your drinking? (3) Have you ever felt 
bad or Guilty about your drinking? (4) Have you 
ever had a drink first thing in the morning to 
steady your nerves or to get rid of a hangover 
(Eye-opener)? 222 — none of which assesses 
directly the quantity and/or frequency of use. 

Likewise, the CRAFFT, a six-item questionnaire 
for screening adolescents for risky alcohol and 
other drug use (excluding nicotine) asks: (1) 
Have you ever ridden in a Car driven by 



s See Appendix H. Reliability is whether the 
instrument produces the same results under the same 
conditions when taken on multiple occasions. 
Validity is how accurately the instrument measures 
what it is intended to measure. Sensitivity refers to 
an instrument's ability to identify correctly the 
presence of a condition; the higher the sensitivity the 
less likely the instrument is to produce false 
positives. Specificity is an instrument's ability to 
identify correctly those without the condition; the 
higher the specificity, the less likely the instrument is 
to produce false negatives. 



-83- 



someone (including yourself) who was high or 
had been using alcohol or drugs? (2) Do you 
ever use alcohol or drugs to Relax, feel better 
about yourself or fit in? (3) Do you ever use 
alcohol or drugs while you are by yourself 
Alone? (4) Do you ever Forget things you did 
while using alcohol or drugs? (5) Do your 
Family or Friends ever tell you that you should 
cut down on your drinking or drug use? (6) Have 
you ever gotten into Trouble while you were 
using alcohol or drugs? An affirmative answer 
to each question is worth one point and a cut-off 
score of two is recommended for identifying 
risky alcohol and other drug use, 223 even though 
any use of addictive substances by adolescents is 
considered risky. 224 

The typical screening process also may fail to 
distinguish those individuals with a higher level 
of substance involvement and the associated 
health and social consequences (including the 
risk for addiction) from those with lower levels 
of involvement— a distinction necessary for 
providing appropriate interventions. 225 



Chapter V 

Treatment and Management of Addiction 



Addiction is a disease that can be treated and 
managed effectively at venues where regular 
medical care is delivered by physicians, 
including addiction physician specialists, and 
including a multi-disciplinary team of other 
health professionals using an array of evidence- 
based pharmaceutical and psychosocial f 
approaches. In accordance with standard 
medical practice for the treatment of other 
chronic diseases, best practices for the effective 
treatment and management of addiction must be 
consistent with the scientific evidence of the 
causes and course of the disease. Best practices 
require: 1 

• Comprehensive assessment of the extent 
and severity of the disease, determination of 
a clinical diagnosis, evaluation of co- 
occurring health conditions and the 
development of a tailored treatment plan; 



In this report, we have used the general term 
addiction to apply to those who meet criteria for past- 
month nicotine dependence based on the Nicotine 
Dependence Syndrome Scale (NDSS) and those who 
meet diagnostic criteria for past year alcohol and/or 
other drug abuse or dependence (excluding nicotine) 
in accordance with the Diagnostic and Statistical 
Manual of Mental Disorders (DSM-IV). (The DSM 
refers to substance abuse and substance dependence 
collectively as substance use disorders. The criteria 
for nicotine dependence in the NDSS parallel those 
of the DSM-IV.) This definition is consistent with 
the current move to combine abuse and dependence 
into an overarching diagnosis of addiction in the 
upcoming DSM-V. 

f Psychosocial therapy is a general term for non- 
pharmaceutical-based interventions and includes 
various forms of individual and group psychotherapy 
that address psychological, behavioral and social 
issues that contribute to risky substance use and 
addiction. Behavioral therapies are those 
psychosocial interventions that focus more directly 
on addressing the patient's substance-related 
behaviors, typically through behavioral reinforcement 
approaches, with less of an emphasis on the 
psychological or social determinants of their 
substance use. 



-85- 



• Stabilization of the patient's condition via 
cessation of substance use and medically 
supervised detoxification, when necessary, 
as a precursor to treatment; 

• Acute Care via evidence-based 
pharmaceutical and/or psychosocial 
addiction treatments, accompanied by 
treatment for co-occurring health conditions, 
delivered by qualified health professionals; 

• Chronic Disease Management to help the 
patient maintain the progress achieved 
during acute treatment and prevent relapse. 
The process should be medically supervised 
and should involve pharmaceutical and/or 
psychosocial therapies and continued 
management of co-occurring health 
conditions as indicated; and 

• Support Services including encouragement 
to participate in mutual support programs 
and the provision of auxiliary support 
services such as legal, educational, 
employment, housing and family supports. 

A Comprehensive Approach to 
Treatment 

A comprehensive approach to addiction requires 
recognition of addiction as a primary disease and 
that all substances and behaviors associated with 
addiction are addressed in treatment, rather than 
a focus only on an individual addictive 
substance. It is all too common, for example, 
for addiction involving nicotine to be ignored in 
the course of treating addiction involving 
alcohol or other drugs. Accordingly, when 
treating addiction, it is critical to recognize the 
high rates of co-occurrence of different 
manifestations of addiction and the possibility of 
the existence of an addiction syndrome, in which 
common pathways underlie related addictive 
behaviors (e.g., obesity or bulimia and addiction 
involving alcohol) and in which individuals may 
switch from one object of addiction* to another 
(e.g., from prescription opioids to heroin, from 
addictive substances to pathological gambling). 5 



Including the source of reward or relief. 



Similarly, treatments for one manifestation of 
addiction tend to have spillover effects, either 
ameliorating the symptoms of other 
manifestations of addiction or proving effective 
in the treatment of multiple expressions of 
addiction (e.g., naltrexone for the treatment of 
addiction involving opioids, alcohol as well as 
gambling). 6 



When treatment is too highly focused on a 
specific substance or behavior, it may not be 
addressing the actual underlying causes of the 
addiction or the possibility of "addiction 



Numerous studies have shown that addiction 
treatments are just as effective as those for other 
illnesses. 2 

-Alan I. Leshner, PhD 
Chief Executive Officer 
American Association for the 
Advancement of Science 
Executive Publisher, Science 
Former Director 
National Institute on Drug Abuse (NIDA) 

/7 would define treatment for addiction] the way I 
would define treatment for any medical problem- 
good thorough evaluation, intervention tailored 
for that specific person based on a good 
assessment, use of a range of tools— behavioral, 
pharmacological, family and other social support, 
housing, jobs? 

—John Rotrosen, MD 
Professor, Department of Psychiatry 
New York University School of Medicine 
VA NY Harbor Healthcare System 

The goal of the 'good and modern ' system is to 
provide a full range of high-quality services that 
meet the range of age, gender, cultural and other 
circumstances that the individual brings to 
treatment. It is grounded in a public health model 
that addresses system and service coordination; 
health promotion and prevention, screening and 
early intervention; treatment and recovery; and 
resiliency supports to promote social integration 
and optimal health and productivity? 

~H. Westley Clark, MD, JD, MPH 
Director 

Center for Substance Abuse Treatment, SAMHSA 



-86- 



hopping," where a patient replaces one addiction 
object with another. Treating the disease of 
addiction involves addressing not only the 
specific object of the addiction, but the 
antecedents, manifestations and consequences of 
addiction more generally. 7 



addiction diagnosis, establish whether co- 
occurring medical, including mental health, 
problems exist and allow for the development of 
an appropriate and specific treatment plan. 10 

Assessment tools, as distinguished from 
screening tools, are meant to determine the 
presence and severity of a clinical condition and 
should parallel, at least in part, established 
diagnostic criteria for the disease. 1 Assessments 
tools also might examine social, family and 
personal factors that might relate to or co-occur 
with substance use. 1 1 This information can help 
health care practitioners determine the most 
appropriate intervention for their patients. 

A comprehensive assessment helps to create the 
foundation for effective treatment that is 
individualized and tailored to the patient. 5 12 
The assessment should gather information about 
many aspects of the individual including the 
physiological, behavioral, psychological and 
social factors that contribute to the patient's 
substance use and that might influence the 
treatment process. 13 For example, in addition to 
determining the patient's health status, the stage 
and severity of the disease 14 and the family 
history of addiction, the assessment should 
determine personality traits such as 
temperament; family and social dynamics; the 
extent and quality of the patient's family and 
social support networks; prior treatment 
attendance and response to previous treatment 
experiences; 15 and the patient's motivation and 
commitment to disease management. 
Assessments also should cover the situations and 
behaviors that may increase risk for relapse and 
those that protect against relapse. 16 It is 
important that assessment instruments also offer 
some degree of cultural sensitivity and that they 
are age and gender appropriate. 17 



' See Appendix H for some examples of assessment 
instruments used by practitioners and researchers to 
help make these diagnoses. 

* This, however, is not always the case in commonly- 
used assessment instruments (see Appendix H). 
§ Much of the research on comprehensive 
assessments relates to addiction involving alcohol. 



The bottom line is that addiction is an illness that 
we are able to treat and manage, if not cure, 
provided that we focus on the person with the 
addiction, the family and the community— a 
holistic approach to a sprawling problem* 

-Harold S. Koplewicz, MD 
Child and Adolescent Psychiatrist 
President 
Child Mind Institute 



Assessment 

Once a patient has been screened for risky use 
and identified as requiring professional services 
beyond a brief intervention, a physician- 
working with other health professionals-should 
perform a comprehensive assessment of the 
patient's medical, psychological and substance 
use history and current health status, present 
symptoms of addiction, potential withdrawal 
syndrome and related addictive behaviors. This 
thorough assessment is a necessary precursor to 
treatment initiation and must involve a trained 
physician. 9 The assessment should utilize 
reliable and valid interview-based instruments 
and biological tests as needed. The goals of the 
assessment are to help the provider determine 
the nature, stage and extent of the disease and 
whether the patient meets clinical criteria for an 



Despite the distinction between screening and 
assessment tools, the term screening often is used to 
subsume the concept of assessment or 
interchangeably with the term in the clinical and 
research literatures. Furthermore, while there is some 
overlap between screening or assessment procedures 
used to identify risky substance use and methods 
used to diagnose a clinical addiction, a formal 
diagnosis of addiction should be based on the 
demonstration of specific symptoms included in the 
most recent versions of the Diagnostic and Statistical 
Manual of Mental Disorders (DSM) or the 
International Statistical Classification of Diseases 
(see Chapter II). 



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The comprehensive assessment should result in 
a treatment plan that is developed in concert 
with the patient by a physician with input from 
other health professionals. The treatment plan 
should articulate clearly the treatment goals and 
particular interventions aimed at meeting each of 
those goals. The plan should be monitored and 
revised as needed should the patient's status or 
needs change. 18 

The comprehensive assessment also should 
result in a detailed and thorough written report, 
which should be incorporated into the patient's 
health record, that: 

• Provides a clinical diagnosis and identifies 
the particular manifestations and severity of 
the disease; 

• Identifies factors that contribute to or are 
related to the disease; 

• Identifies a treatment plan to address these 
risk factors and ensure that the treatment 
plan is implemented and monitored 
effectively; and 

• Provides connections to specialty care— i.e., 
an addiction physician specialist or other 
specialty providers-as needed and to 
auxiliary and support services. 19 

Stabilization* 

The first step in addressing addiction involving 
nicotine, alcohol or other drugs is cessation of 
use and, if necessary, medically managing the 
clearance of toxic substances from the patient's 
system via a clinical process often referred to as 
detoxification. Detoxification itself addresses 
intoxication or withdrawal but is not treatment 
of addiction. 20 In most cases, cessation of use is 
the necessary first step to formal treatment 
protocols. While cessation of use can in some 



Note that some of the medications described for use 
in the stabilization (tobacco cessation and 
alcohol/other drug detoxification) process will be 
described in greater detail later in this chapter in the 
discussions of acute treatments for addiction and 
chronic disease management. 



cases be a self-managed process, patients 
typically need professional assistance. 

Cessation of Use 

Tobacco. Smoking cessation, while unpleasant 
for most persons going through it, is not unsafe 
and does not require medical monitoring. 
Patients undergoing smoking cessation may 
experience certain withdrawal symptoms 
including cravings, irritability, impatience, 
hostility, anxiety, depressed mood, difficulty 
concentrating, decreased heart rate, increased 
appetite and sleep disturbances. 21 The calming 
effect many smokers feel when smoking usually 
is associated more with the relief of nicotine 
withdrawal symptoms than with the effects of 
the nicotine itself. Withdrawal symptoms can 
commence in as little as a few hours after the 
last dose of nicotine, peak within a few days, 
and either subside within several weeks or, in 
some cases, persist for months. 22 

Nicotine replacement therapy (NRT)-through 
the use of nicotine patches, gum, nasal spray, 
inhalers, lozenges and sub-lingual tablets-is a 
common pharmaceutical aid for persons 
attempting smoking cessation. NRT lessens 
withdrawal symptoms, increasing the chance 
that a smoker will quit successfully. 23 NRT 
replaces some of the nicotine formerly obtained 
by smoking. 24 However, the nicotine in NRT is 
delivered more slowly and at lower dose levels 
than through smoking, so NRT is more likely to 
reduce cravings than wholly eliminate them. 25 
Some NRTs mimic the sensations of smoking 
(the inhaler) or otherwise occupy the mouth 
(gum, lozenges and sub-lingual tablets). 26 
Research indicates that the most effective use of 
NRT involves replicating the experience of 
smokers: using nicotine patches to maintain a 
baseline serum nicotine level along with the gum 
or lozenges to produce a boost of serum nicotine 
levels periodically. 27 

Other pharmaceutical therapies such as 
antidepressants (bupropion SR) and nicotine 
agonists (varenicline) can help people quit 



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smoking and maintain their abstinence. 

Alcohol and Other Drugs. Some patients with 
addiction involving alcohol and other drugs can 
reduce and ultimately cease substance use 
without medical supervision, particularly if they 
are not physically dependent on the substances 
involved, the disease is not advanced and they 
have sufficient personal supports to help them 
through the cessation process. 

Detoxification 

For patients who demonstrate physical 
dependence on a substance, cessation of use on 
their own may be unsafe and medically 
supervised detoxification may be required to 
manage withdrawal symptoms and 
complications. 29 

Detoxification occurs when toxic substances that 
come from the ingestion of alcohol or other 
drugs are removed from the body via 
metabolism through the liver and excretion 
through the kidneys. 30 Medically-assisted 
detoxification aims to reduce the risk of 
discomfort and potential physical harm for 
patients who are experiencing withdrawal. 31 

The detoxification process often requires the 
assistance of medical professionals and may 
involve the use of pharmaceutical therapies to 
guide people safely through withdrawal. 
Medical professionals may collaborate with 
supportive, non-medical personnel or with 
medical personnel in other health facilities to 
facilitate the withdrawal process. 32 
Detoxification is an important and often 
necessary prerequisite to effective acute 
addiction treatment. 33 It should serve as the 
catalyst for entry into the treatment system but 
does not itself constitute treatment. 34 

There are three main components to effective 
detoxification: 



These medications are described in more detail later 
in the chapter. 

' Physical dependence is characterized by symptoms 
of tolerance and/or withdrawal (see Chapter II). 



1 . Evaluation. Examine the patient and 
determine if symptoms are acutely present- 
ideally using standardized instruments to 
measure the severity of withdrawal 35 — and 
documenting vital signs and other physical 
manifestations of withdrawal. Assess for 
the presence of co-occurring medical and 
mental health conditions and determine, 
through the use of drug testing, which 
substances are present in the person's body 
or were used recently. 36 

2. Stabilization. Assist patients through 
withdrawal to re-establish a state of 
physiological stability with or without the 
use of medications. 37 

3. Facilitation of Treatment Entry. Provide or 
connect patients to addiction treatment and a 
continuing care plan. 38 

Alcohol Detoxification. In alcohol 
detoxification services, the cessation of alcohol 
ingestion in an alcohol-tolerant individual is 
coupled with certain medications to help prevent 
the dangerous effects that may accompany 
alcohol withdrawal. Withdrawal from alcohol 
typically takes up to seven to 10 days, but with 
medical management, stabilization can be 
achieved sooner. § 39 During the first six to 48 
hours of withdrawal from alcohol, symptoms 
may include anxiety, nausea, agitation and 
difficulty concentrating. 40 More severe 
symptoms can include hallucinations and 
seizures. 41 Alcohol withdrawal delirium, also 
known as delirium tremens (DTs), is the most 
severe and dangerous withdrawal symptom and 
usually appears two to four days after the last 
drink. 42 Some symptoms of alcohol withdrawal, 
including DTs and seizures, can be life- 



1 These include the Clinical Institute Withdrawal 
Assessment-Alcohol Revised (CIWA-Ar), the 
Clinical Opiate Withdrawal Scale (COWS) and the 
Finnegan Neonatal Abstinence Score. 
§ The duration of detoxification varies with the 
severity of addiction and some withdrawal 
symptoms, such as sleep disturbances, may persist for 
several weeks. 



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threatening. These withdrawal symptoms can 
be more severe in persons who have undergone 
prior multiple episodes of alcohol withdrawal, a 
process known as the kindling effect. ' 44 

Benzodiazepines, which have calming, sedating 
effects, have been shown to prevent the onset of 
certain alcohol withdrawal symptoms and 
acutely relieve such symptoms including 
alcohol-induced seizures and DTs. 45 A large 
review study found that whereas 
benzodiazepines are more effective than 
placebos at treating seizures in patients going 
through alcohol withdrawal, there is no evidence 
that they are more effective than other 
medications used to treat alcohol withdrawal 
syndrome or that particular benzodiazepines are 
more effective than others. 46 Benzodiazepines 
commonly used to treat the anxiety and agitation 
symptoms associated with alcohol withdrawal 
include diazepam, 1 47 chlordiazepoxide, 48 
lorazepam and oxazepam. 49 

Because the combined effects of 
benzodiazepines and alcohol can be life 
threatening or even fatal, 50 patients must be 
advised not to drink while on benzodiazepine 
medications. This is particularly important since 
benzodiazepines commonly are prescribed for 
alcohol withdrawal on an outpatient basis where 
patients' drinking may not be monitored 
adequately. 51 Another cautionary note is that 
benzodiazepines have addictive potential in their 
own right; therefore, their use must be 
monitored carefully. 52 

Carbamazepine, an anti-seizure medication, may 
be an effective alternative to benzodiazepine 
medications for treating alcohol withdrawal. 53 
Carbamazepine also may be effective at 



Although DTs occur only in about five percent of 
patients undergoing detoxification, mortality from 
DTs historically has been as high as 18.5 percent. 
Swift detection and proper treatment can lower this to 
about five percent. 

' Kindling is the increase in neuronal responses 
produced by repeated stimulation. Kindling leads to 
a worsening of withdrawal symptoms with each 
attempt at alcohol detoxification. 
* Diazepam also may relieve muscle spasms and 
seizures associated with alcohol withdrawal. 



addressing alcohol cravings. The medication's 
ability to treat seizures, the minimal potential for 
misuse, the significant potential to treat mood 
disorder and the lack of sedating effects are 
some of its advantages. 55 

Opioid Detoxification. For patients with 
addiction involving illicit or prescription 
opioids, including heroin, hydrocodone or 
oxycodone, withdrawal symptoms are not life 
threatening, but they can be extremely 
uncomfortable 56 and must be managed 
effectively to prevent relapse. 57 Opioid 
withdrawal symptoms can include abdominal 
pain, muscle aches, agitation, diarrhea, dilated 
pupils, insomnia, nausea, runny nose, sweating 
and vomiting. 58 Withdrawal symptoms 
generally last from seven days to several 
weeks. 59 Because medical complications can 
develop, patients must undergo regular 
monitoring including physical examinations, a 
complete review of the functioning of the body's 
organs and psychological status and, when 
necessary, laboratory evaluations. 60 

The goal of medical detoxification is a safe, 
comfortable and complete withdrawal from 
opioids. Abrupt discontinuation of opioids, 
especially for a patient who has developed 
physical dependence on the drug, typically is not 
recommended; instead, in the case of such 
dependence involving prescription opioids, the 
patient is tapered or weaned off the opioid 
medication. 5 61 However, for addiction 
involving illicit opioids, it is not legal to 
prescribe a tapering dose of the illicit drug so 
another method must be used. 

An alternative to tapering is management of 
withdrawal symptoms using non-opioid 
medications-such as clonidine 62 -to decrease the 
agitation and discomfort associated with opioid 
withdrawal, or other medications that can relieve 
the symptoms of acute withdrawal such as 
nonsteroidal anti-inflammatory drugs (NSAIDs) 
to treat muscle pain, antiemetics for nausea and 
non-addicting sleeping medications such as 



The use of a tapering dose calculator can help in 
this process and can be accessed online at: 
www.agencymeddirectors.wa.gov/guidelines.asp 



-90- 



trazadone to treat insomnia. Detoxification 
also can be achieved using specific medically- 
prescribed opioids that have less potential for 
misuse (methadone or buprenorphine) and then 
tapering the patient off these medications when 
possible. 64 

The prescription of methadone for addiction 
treatment is restricted by federal regulations;* it 
only can be prescribed for detoxification from 
opioids in licensed facilities. ' 65 Buprenorphine 
can be dispensed or prescribed for illicit or 
prescription opioid withdrawal in any outpatient 
setting by qualified physicians who have the 
required waiver from the Drug Enforcement 
Administration (DEA).* 66 While use of these 
medically-prescribed opioids can result in 
physical dependence, they are considered less 
dangerous because they have less potential for 
misuse and addiction than other opioids; 5 67 they 
also are prescribed to patients by a licensed 
physician in a medical care setting. They work 
by occupying the opioid receptors in the brain, 
blocking or minimizing the effects of more 
addicting opioid drugs; therefore, a patient on 
methadone or buprenorphine maintenance 
largely is protected from inadvertent overdose. 68 

CNS** Stimulant Detoxification. Cessation of 
CNS stimulant (cocaine, amphetamine) use may 
result in withdrawal symptoms if the user 



It is not restricted when prescribed for pain 
management. 

1 Unless a patient has been hospitalized for another 
medical condition. 

* Becoming qualified to prescribe and distribute 
buprenorphine involves an eight-hour approved 
program in treating addiction involving opioids, an 
agreement that the physician/medical practice will 
not treat more than 30 patients for addiction 
involving opioids with buprenorphine at any one time 
within the first year and up to 100 thereafter, and 
assurance that the trained physician will refer patients 
to necessary supplemental psychosocial services. 
Physicians who meet the qualifications are issued a 
waiver by the Substance Abuse and Mental Health 
Services Administration (SAMHSA) and a special 
identification number by the DEA. 
§ Methadone and buprenorphine also are used for 
stabilization and maintenance of addiction involving 
opioids. 

** Central Nervous System. 



develops addiction involving these drugs; these 
symptoms are not life-threatening and generally 
are less severe than those associated with 
withdrawal from alcohol or opioids/ r 69 
Symptoms of stimulant withdrawal commonly 
include decreased energy, insomnia, agitation, 
increased appetite, depressed mood, anxiety and 
drug craving. 70 

Evidence for the effectiveness of pharmaceutical 
detoxification to assist in stimulant withdrawal 
is limited. 7 A vaccine to treat addiction 
involving cocaine and ease withdrawal 
symptoms currently is being tested. tt 72 But 
more research is needed to determine the 
vaccine's place in the cocaine detoxification 
process and how it can be implemented safely. 73 
Although there are no available medications 
proven to be effective in mitigating the 
symptoms of amphetamine withdrawal, 74 several 
medications currently being researched may 
prove useful in alleviating the symptoms. §§ 75 

CNS Depressant Detoxification. Withdrawal 
from CNS depressants may produce 
complications and, in some circumstances, can 
be life-threatening. 76 Symptoms of withdrawal 
from certain prescription CNS depressants, such 
as benzodiazepines, are similar to those for 
alcohol withdrawal, with seizures and delirium 
being the most serious. In the elderly, there is a 
risk of falls and myocardial infarctions during 
benzodiazepine withdrawal. 77 Benzodiazepine 
withdrawal symptoms more specifically include 
seizure, hypersensitivity, impaired perception of 
movement, nausea and tension. It is 
common for people detoxifying from 



1 During withdrawal from stimulants, there is a risk 

of depression or negative thoughts and feelings that 

may lead to suicidal thoughts or attempts. 

** See page 98 for a discussion of vaccines under 

development for addiction treatment. 

§§ Drugs under investigation for this purpose include 

modafinil, propranolol and bupropion; these 

investigations are of off-label uses of approved drugs. 

Symptoms of withdrawal from benzodiazepines 
often mimic the conditions for which those drugs 
initially were prescribed-mood and anxiety 
disorders. As such, it sometimes is unclear if the 
patient is presenting with withdrawal symptoms or 
with symptoms of the underlying condition. 



-91- 



benzodiazepines to experience significant 
withdrawal symptoms lasting between 10 and 14 
days, 79 and symptoms can persist for four to six 
months. 80 Therefore, it is recommended that 
benzodiazepine detoxification extend over a 
period of weeks or months-tapering the patient 
off the drugs over time. Another option for 
detoxification from benzodiazepines is to 
prescribe a different drug from the class, one 
with a longer half-life, such as 
chlorodiazepoxide or clonazepam. 81 

Detoxification Venues. Detoxification can take 
place in a variety of settings including the 
patient's home (monitored and managed by 
trained clinicians), physicians' offices, non- 
hospital addiction or mental health treatment 
facilities, urgent care centers and emergency 
departments, intensive outpatient and partial 
hospitalization programs and acute care inpatient 

* 82 

settings. 

For planned, monitored or medically-assisted 
detoxification, health-care providers, considering 
the specific needs of the patient, typically 
determine the venue for detoxification. Patients 
should be placed in the least restrictive setting 
possible. 83 Beginning in the 1970s, there was a 
movement toward medical ambulatory 
detoxification, primarily for alcohol, that 
maintained high safety and efficacy profiles while 
being more cost effective than inpatient 
detoxification. Ambulatory care was intended to 
supplement rather than replace inpatient medical 
detoxification with the understanding that there 
were some people for whom inpatient care still 
was necessary. The ability to continue to meet life 
responsibilities as well as relatively lower costs 
are advantages of outpatient detoxification. 84 

The primary substance involved in the addiction, 
the severity of the symptoms and particular 
patient characteristics (e.g., age, co-occurring 
substance use and other health conditions) all 
play important roles in determining the 
appropriate venue for detoxification. For 



Such as acute care general hospitals, acute care 
addiction treatment units within those hospitals, acute 
care psychiatric hospitals and other specialty 
hospitals licensed to provide addiction treatment. 



example, patients with a history of severe 
withdrawals or multiple withdrawals should not 
be placed in nonmedical settings for 
detoxification. 85 For patients deemed a danger 
to themselves or others, medically-managed 
intensive inpatient treatment or emergency 
hospitalization in a psychiatric facility is 
recommended. 86 For patients with mild or 
moderate withdrawal symptoms, outpatient 
detoxification can be just as effective as 
inpatient, provided the patients have a positive 
and helpful social support network. 87 

Acute Care 

Effective, clinical treatments for addiction 
include a significant and growing range of 
pharmaceutical and/or psychosocial therapies 
delivered by qualified health professionals. Due 
to the complex nature of addiction and its 
physiological, psychological and environmental 
risk factors, a multi-pronged approach to its 
treatment that includes a combination of 
pharmaceutical and psychosocial therapies 
typically yields the best results. 88 Because of the 
extent to which addiction co-occurs with a broad 
range of other health problems, effective 
medically-managed acute treatment protocols 
also should address both co-occurring disorders 
and patients' nutrition and exercise 

on 

requirements. 

Guidelines set forth by the American Society of 
Addiction Medicine's (ASAM) patient 
placement criteria increasingly are being used by 
treatment programs, government programs, 
managed care companies and other 
organizations to appropriately match patient 
needs to specific treatment services and to 
determine the appropriate level of care. 90 

Pharmaceutical Therapies 

As with most medical conditions, 
pharmaceutical therapies can be an important 
component of addiction treatment, 91 particularly 
for patients who are highly motivated to adhere 
to the medication regimen.' 92 (Table 5.1) 



1 For less motivated patients, supervised 
administration of the medication may be necessary. 



-92- 



Table 5.1 

Food and Drug Administration (FDA) Approved and Promising Pharmaceutical Therapies and 

the Types of Substances They Address 



Type of Medication" 93 


Addiction 


Addiction 


Addiction 


Addiction 


Addiction 




Involving 
Alcohol 


Involving 
Nicotine 


Involving 
Cocaine 


Involving 
Opioids 


Involving 
Marijuana 


Reduce Craving/ 
Withdrawal Symptoms 


Acamprosate (Campral) 


L X 










Bupropion (Zyban, 
Wellbutrin) 




X 








Nortriptyline (Pamelor, 
Aventyl) 




X* 








Clonidine (Catapres) 




X* 








Baclofen (Kemstro, 
Lioresal, Gablofen) 


X* 










Ondansetron (Zofran) 


X* 






X* 




Gabapentin (Fanatrex, 
Gabarone, Gralise, 










X* 


Neurontin) 












Reward Reduction ] 


Disulfiram (Antabuse) 


X 










Naltrexone (Re Via, 
Depade, Vivitrol) 


X 






X 




Varenicline (Chantix) 




X 








Modafinil (Provigil, 






X* 






Alertec, Modavigil) 












Topiramate (Topamax) 


X* 




X* 






Vaccines 




X* 


X* 






Maintenance/Medication- 












Assisted Therapies 












Nicotine Replacement 
Therapy (NRT) 




X 








Methadone 








X 




Buprenorphine/Naloxone 
(Subutex, Suboxone) 








X 




Oral Tetrahydrocannabinol 
(THC) 










X* 



a Some of these medications are FDA-approved for treating addiction involving the particular substance, while 
others are not. Specifically, the X indicates the type of substance for which the medication has demonstrated 
efficacy and has received FDA-approval for use in the treatment of addiction involving the noted substance. The 
X* notation indicates that ongoing research is demonstrating promising clinical utility for the medication or 
research already has demonstrated clinical utility for the medication in treating addiction involving the noted 
substance, but these medications are not (yet) approved by the FDA for use as a pharmaceutical treatment for 
addiction involving that particular substance. Medications that have been approved by the FDA for other purposes 
can be prescribed off- label (for uses other than that for which it received FDA approval) based on clinical 
evidence. However, in spite of clinical evidence of efficacy, these medications may never receive FDA approval 
since adding new indications to a medication's FDA-approved label would necessitate significant investments in 
FDA-required studies. 94 



-93- 



Pharmaceutical agents for addiction treatment 
may work via one of the following mechanisms 
of action or by a combination of these 
mechanisms: 

• Reducing cravings for the addictive 
substance and/or reducing aversive 
withdrawal symptoms; 

• Creating an aversion to the addictive 
substance or attenuating the rewarding 
effects of the addictive substance, eventually 
limiting its appeal; or 

• Producing moderated effects resembling 
those of the addictive substance and serving 
as a less addicting replacement for the 
substance of addiction. 

Differences in the factors that contribute to 
addiction and that determine how the disease 
will manifest itself require different and tailored 
approaches to treatment, particularly with regard 
to pharmaceutical treatments. For example, 
individuals with addiction involving alcohol 
who drink primarily for the rewarding effects 
may be quite different biologically from those 
who drink primarily as a means of relieving 
stress or reducing negative feelings; as such, the 
efficacy of a specific pharmaceutical treatment 
may depend on whether it addresses the reward 
experienced from using the addictive substance 
or whether it serves as a safer medication for 
providing relief from negative feelings. 96 
Likewise, certain genetic or biological 
characteristics may determine how effective a 
certain type of pharmaceutical intervention will 
be for an individual with addiction; for example, 
naltrexone has been found to be a more effective 
medication for the treatment of addiction 



For ease of presentation, a medication is categorized 
in this discussion based on its primary mechanism of 
action. 

* In individuals with a significant genetic 
susceptibility, progression from use to addiction is 
relatively quick and severe, whereas in individuals 
with a low genetic susceptibility, progression from 
use to addiction will result from prolonged exposure 
to addictive substances and considerable 
environmental risk factors, such as stress. (See 
Chapter II.) 



involving alcohol in patients with a family 
history of the disease than in those without a 
family history. 97 A true understanding of these 
differences is in its infancy, but appears to be a 
critical factor in tailoring pharmaceutical 
treatments to achieve the maximum therapeutic 
benefit. 98 



Medications that Reduce Craving and/or 
Withdrawal Symptoms. A number of 
medications work on the brain chemicals and 
pathways of individuals with addiction to reduce 
cravings for the addictive substance and in some 
cases reduce symptoms of withdrawal from the 
substance. 

Acamprosate (brand name Campral), approved 
by the Food and Drug Administration (FDA) in 
2004 to treat addiction involving alcohol, helps 
to normalize brain activity and function that has 
been disrupted by heavy alcohol use 99 and 
reduce withdrawal symptoms such as anxiety 
and insomnia. 100 It is prescribed for treatment 
patients who have discontinued their use of 
alcohol. 101 

Studies regarding the effectiveness of 
acamprosate have been mixed in the U.S., but 
more consistently positive in Europe. 1 102 
Several large-scale, controlled studies have 
found that acamprosate can double the 
abstinence rate among treatment patients at one 
to two years following program completion 
compared to patients who receive placebos, and 



1 The differences in effectiveness findings appear to 
be due to methodological differences. 



What we hope to do is to actually have a menu 
of treatments that clinicians could choose from. 
If one drug doesn't work or they can't tolerate 
it, " patients would "try another one and so 
forth, and hopefully they '11 find one that is 
effective. 

-Raye Z. Litten, PhD 
Associate Director 
Division of Treatment and Recovery Research 
National Institute on Alcohol Abuse 
and Alcoholism (NIAAA) 



-94- 



is associated with better treatment retention 
rates. 103 Acamprosate generally is safe to use, as 
it does not appear to have a potential for 
addiction, has virtually no overdose risk, has 
mostly mild side effects and does not interact 
significantly with other medications. 104 

Antidepressant medications also have proven to 
be effective in smoking cessation. The 
mechanism driving the efficacy of 
antidepressants as cessation agents is not yet 
fully understood. It may be that antidepressant 
medications compensate for nicotine's anti- 
depressive effects during withdrawal, lessening 
this withdrawal symptom. Alternatively, 
antidepressant medications may work- 
independent of their antidepressant qualities—on 
the neural pathways or the nicotine receptors 
that are active in addiction involving nicotine.* 

105 

• Bupropion sustained release (SR) (brand 
names Zyban and Wellbutrin) is a 
prescription antidepressant medication that 
can be used alone or in combination with 
nicotine replacement therapy (NRT) for 
smoking cessation. 105 It is believed to work 
by minimizing cravings and withdrawal 
symptoms during the early stages of tobacco 
cessation. 107 Bupropion may be effective in 
relieving negative mood and feelings that 
smokers may experience when going 
through smoking cessation. 108 The 
neurological effects of bupropion that aid in 
its efficacy as a cessation medication may 
include blocking the re-uptake of two 
neurotransmitters that are active in addiction 
involving nicotine— dopamine and 
norepinephrine— and blocking nicotine 
receptors. 109 The medication reduces the 
severity of nicotine withdrawal and the 
depression that may accompany smoking 
cessation. 110 Another advantage of 
bupropion for smoking cessation is that it 
tends to lessen the weight gain that often 
accompanies— and derails-smoking 
cessation attempts. 111 



For example, by blocking nicotine receptors in the 
brain. 



Patients generally are advised to begin daily 
bupropion treatment one to two weeks prior 
to quitting so that adequate blood levels of 
the medication can be reached. 112 The 
standard course of treatment is seven to 12 
weeks, although this period can be extended 
for up to six months if necessary. 113 
Possible side effects include insomnia, dry 
mouth, nausea and a small risk of 
seizures. 114 Bupropion SR carries a black 
box warning' of increased suicidal 
tendencies among children, adolescents and 
young adults. 115 

A meta-analysis of 24 bupropion studies 
found that the drug can nearly double 
smokers' chances of achieving abstinence 
lasting longer than five months compared to 
a placebo. 116 Other analyses found similar 
results. 117 The efficacy of the drug does not 
seem to be sensitive to longer follow-up 
periods (up to 12 months), treatment setting, 
dosage or the level of supplementary 
psychosocial therapy. 118 

Bupropion also may be a promising 
treatment for methamphetamine addiction; it 
appears to reduce cravings and the 
rewarding effects of methamphetamine. 119 
However, evidence supporting its ability to 
increase abstinence rates is mixed and 
further research is needed to establish 
bupropion as an effective treatment for 
methamphetamine addiction. 120 

• Preliminary research indicates that another 
antidepressant, nortriptyline (brand names 
Pamelor and Aventyl), may be an effective 
smoking cessation aid. 121 Nortriptyline has 
been found to double patients' chances of 
cessation compared to placebos. 122 
However, the medication has not yet been 
approved by the FDA for use as a smoking 
cessation aid; therefore, it only is 
recommended for use by patients who have 
not responded well to NRT or bupropion. 123 



' A black box warning from the FDA denotes the 
most serious warning of adverse effects for a 
medication. 



-95- 



Clonidine (brand name Catapres), a medication 
normally used to lower blood pressure, may 
reduce withdrawal symptoms and assist in 
smoking cessation. 124 However, the many side 
effects associated with clonidine suggests that it 
only be prescribed to patients seeking to quit 
smoking if they are unwilling or unable to use 
other first-line cessation medications. 125 

Baclofen (brand names Kemstro, Lioresal and 
Gablofen), a medication normally used to treat 
spasticity, has been found to reduce cravings and 
withdrawal symptoms in patients with addiction 
involving alcohol, helping them to reduce their 
drinking and to achieve and maintain abstinence; 
however, the existing evidence is too limited to 
recommend baclofen for addiction involving 
alcohol. 126 A double-blind placebo-controlled 
study in humans found that more baclofen 
patients than placebo patients achieved and 
maintained abstinence (70.0 percent vs. 21.1 
percent); baclofen patients also demonstrated a 
larger reduction in average number of drinks, 
alcohol craving, relapse rates and anxiety levels 
relative to placebo patients in this study. 127 
There appears to be a dose-response relationship 
for baclofen, with greater effectiveness at higher 
doses. 128 

Ondansetron (brand name Zofran), an anti- 
nausea drug, 129 has been shown to be effective in 
reducing alcohol use cravings and alcohol use 
among patients with addiction involving alcohol, 
particularly among those with an early onset 
addiction. 130 The drug may be more effective in 
patients with specific genotypes. ' 131 There also 
is emerging evidence that ondansetron might be 
effective in treating withdrawal symptoms in 
patients with addiction involving opioids. 132 

Gabapentin (brand names Fanatrex, Gabarone, 
Gralise, Neurontin), a medication used to treat 
neuropathic pain and epileptic seizures, has been 
found to reduce withdrawal symptoms and the 



Sample size of 39. 
' Specifically, those with the L/L genotype of the 
5HTTLPR polymorphism. "L" signifies long alleles 
and "S" signifies short alleles. Possible genotypes 
are L/L, S/S and S/L. 



use of marijuana in patients with addiction 
involving cannabis. 133 

Reward Reduction Medications. Certain 
medications work to reduce the rewarding or 
pleasurable effects of addictive substances, over 
time decreasing their appeal. 

Disulfiram (brand name Antabuse), approved by 
the FDA in 1949 to treat addiction involving 
alcohol, works by producing unpleasant 
physiological effects in individuals who 
consume alcohol; these aversive reactions serve 
as a deterrent to alcohol consumption among 
those with addiction involving alcohol* 134 

For addiction involving alcohol, disulfiram 
blocks the production of the enzyme aldehyde 
dehydrogenase which enables the liver to 
metabolize alcohol. 135 The obstruction of this 
process leads to a build up of acetaldehyde § in 
the system, causing hangover-like symptoms- 
nausea, vomiting, flushing, rapid heart rate- 
shortly after alcohol consumption. 136 The 
medication has not been found to reduce 
cravings; its preventive qualities come from 
replacing the pleasurable effects of alcohol with 
unpleasant effects. 137 

Although disulfiram is one of the oldest 
pharmaceutical treatments for addiction 
involving alcohol, there are few scientifically 
valid studies of its efficacy. 138 The medication 
appears to be most effective when its use is 
supervised to assure compliance. 139 Researchers 
suggest that the relatively limited evidence of 
the efficacy of the drug may be linked to low 
adherence rates: in one study only 20 percent of 
participants who completed the trial complied 
with disulfiram treatment. Among patients who 
completed the trial, those who received a 



* Disulfiram is the most commonly-used aversion 
medication for the treatment of addiction involving 
alcohol. Another example of a medication that 
produces a similar aversive effect in individuals who 
consume alcohol is calcium carbimide (brand name 
Temposil); other medications used for non-addiction 
clinical purposes, such as cephalosporins which are 
used to treat bacterial infections, have side effects 
similar to disulfiram when alcohol is consumed. 
§ The major metabolite of ethanol. 



-96- 



standard dose of disulfiram reported 
significantly fewer drinking days than their 
peers over the course of a year. 140 One 
explanation for the variation in effectiveness 
may be related to addiction severity: those with 
more severe addiction may drink despite the 
adverse reactions caused by disulfiram, or avoid 
taking the medication altogether. 141 

Naltrexone, used in the treatment of addiction 
involving alcohol and opioids, blocks opioid 
receptors in the brain, leading to reductions in 
the reinforcing effects of these drugs. 142 It does 
this by disrupting the transmission of dopamine - 
-and thus the endorphin rush-caused by alcohol 
and opioid ingestion. 143 

Oral naltrexone (brand names Re Via and 
Depade), which is available as a daily tablet, 
was approved by the FDA to treat addiction 
involving alcohol in 1984. Injectable naltrexone 
(brand name Vivitrol), which is an extended 
release monthly deep intramuscular gluteal 
injection,* 144 was approved by the FDA in 2006 
for addiction involving alcohol and in 20 1 for 
the treatment of addiction involving opioids. 145 
Naltrexone is prescribed for patients who have 
not ingested opioids for seven to 1 days 
because it can cause serious withdrawal 
symptoms if used at the same time as an 
opioid. 146 

Because of naltrexone's mechanism of action — 
reducing the reward or "high" associated with 
substance use— some patients may not take the 
medication regularly. 147 Noncompliance also 
may be associated with experiencing 
uncomfortable side effects ' at the start of a 
course of treatment. 148 Unless participants 
adhere to their treatment regimen 70 to 90 
percent of the time, 1 naltrexone does not 
produce significant outcomes. 149 Injectable 



When injected, the pharmacological agent releases 
its active compound in a consistent way over a long 
period of time. 

1 Side effects can include gastrointestinal problems 
such as nausea, vomiting and abdominal pain and 
central nervous system-related symptoms such as 
headache and fatigue. 

* The necessary adherence rate varies by the duration 
of treatment. 



naltrexone provides two advantages which may 
improve retention and success rates: the need 
for a monthly injection rather than a daily pill 
and the need for regular contact with medical 
and other supporting staff in the course of a 
clinic visit which is required to obtain the 
medication. 150 A disadvantage of the injection 
formulation, however, is that it has more side 
effects at higher doses. 151 

For addiction involving alcohol, the medication 
is more effective at reducing heavy drinking 
than increasing abstinence rates. 152 Several 
randomized, placebo-controlled trials found that 
compared to patients taking placebos, patients 
taking naltrexone report significantly fewer 
drinking days, fewer drinks per drinking day, 
reduced cravings and reduced relapse. 153 

Because naltrexone blocks the euphoric effects 
of opioids and does not produce a high when 
taken, there is much less potential for misuse or 
diversion than there is for other pharmaceutical 
treatments, such as methadone, for addiction 
involving opioids. 154 In one randomized, 
controlled study, patients with addiction 
involving heroin who received naltrexone 
injections were significantly likelier to have 
remained in treatment over the course of the 
study than patients receiving a placebo 
injection. 8 155 Buprenorphine,** when added to 
naltrexone, has been found to improve retention 
in treatment. 156 Relapsing to the use of opioids 
after beginning naltrexone treatment can 
increase patients' risk of overdosing, due to 
naltrexone's effect on increasing the sensitivity 
of opioid receptors in the brain to the effects of 
opioids. 157 

Varenicline (brand name Chantix) is an effective 
therapy for smoking cessation that works by 
reducing the rewarding effects of nicotine 
among patients who smoke while on the 
medication and by reducing the craving and 
withdrawal symptoms that occur among 
abstinent patients. 158 



s Naltrexone patients also were less likely than 
placebo patients to test positive for cocaine, 
benzodiazepine, marijuana and amphetamine use. 
** See page 101. 



-97- 



Research indicates that varenicline use, 
compared with a placebo, can significantly 
increase a patient's chances of attaining 
continual abstinence from smoking over six 
months. 159 A large-scale analysis of several 
randomized controlled trials found that the 
medication was significantly more effective than 
placebos or bupropion in relieving cravings and 
in increasing the likelihood of achieving 
continuous abstinence over a 12-month 



While nausea is the most commonly-reported 
side effect, insomnia, headaches and nightmares 
also are prevalent. 161 In February 2008— two 
years after Chantix was approved-the FDA 
released a public health advisory warning 
patients that the medication has the potential to 
aggravate psychiatric illnesses and in some cases 
lead to the development of neuropsychiatric 
symptoms, such as anxiety, tension, depression 
or suicide attempts. 162 This advisory led to 
modifications in the product labeling and the 
medication guide advising medical professionals 
to monitor all patients taking the medication for 
neuropsychiatric symptoms. 163 More recently, 
medical professionals were advised to monitor 
use of the medication among patients with 
cardiovascular disease since Chantix has been 
linked to adverse cardiovascular effects in these 
patients. 164 

Modafinil, a stimulant medication (brand names 
Provigil, Alertec and Modavigil), used to treat 
narcolepsy and other sleep disorders, reduces the 
stimulating effects of cocaine. 165 At the same 
time, it may reduce cocaine cravings and 
withdrawal symptoms. 166 In one study, patients* 
with addiction involving cocaine who received 
daily doses of modafinil for eight weeks 
submitted nearly twice as many clean urine 
samples than placebo patients during the course 
of the study and were more than twice as likely 
to achieve at least three weeks of prolonged 
abstinence. 167 Another study found modafinil to 
be effective in reducing cocaine use and cocaine 
craving in patients with addiction involving 



Who met clinical diagnostic criteria for dependence 
and who used at least $200 worth of cocaine during 
the prior month. 



cocaine who took part in individual 
psychosocial therapy. 168 

Topiramate (brand name Topamax), an 
anticonvulsant, has been validated by 
randomized controlled trials to treat addiction 
involving alcohol. 169 It is believed to work by 
reducing the release of dopamine and thus the 
rewarding effects of alcohol use and the urge to 
drink. 170 It appears to reduce alcohol withdrawal 
symptoms and can be used in patients who are 
not yet abstinent from alcohol. 171 Topiramate 
also is a promising pharmaceutical treatment for 
addiction involving cocaine, but additional 
research is needed to establish its efficacy. 172 
Preliminary research suggests that the 
anticonvulsant and mood-stabilizing medications 
carbamazepine and valproate also may be 
effective in treating addiction involving 
alcohol. 173 

Vaccines. Recent research in pharmacotherapy 
for substance addiction has examined the use of 
vaccines in the treatment process. 174 These 
vaccines work by producing a sufficient quantity 
of antibodies that bind to the substance and 
prevent or significantly impede it from entering 
the brain,* reducing the accumulation of the 
substance in the brain and ultimately decreasing 
its rewarding effects. 175 Much of the work on 
vaccines for addiction is still in the preclinical 
phase of development. 176 

Vaccines for addiction involving nicotine 5 are 
farthest along in the development phase. They 
are proving to be safe, with limited adverse side 
effects and have shown promise for helping 
smokers quit. 177 However, these vaccines still 
are undergoing clinical trials to test for safety 
and efficacy. While they may be helpful in 
reducing the rewarding effects of nicotine in 
those who already are addicted, they do not 



1 Who did not have co-occurring addiction involving 
alcohol. 

* Antibodies typically are comprised of larger 

molecules than addictive substances, making them 

less able to cross into the brain. 

§ NicVax, Nic002 (also known as NicotineQB) and 

TA-Nic are the vaccines currently under 

investigation. 



-98- 



prevent addiction and should be used in 
conjunction with other therapeutic 
approaches. 178 

A cocaine vaccine also has been developed and 
was found in a preliminary study to reduce 
cocaine use. 179 Researchers also are exploring a 
vaccine or antibody administrations for other 
addictive stimulants including 
methamphetamine 180 and phencyclidine (PCP) 181 
and have found promising results in animal 
samples. 

Maintenance Medications/Medication 
Assisted Therapies. Certain medications used 
to treat addiction function by delivering a less 
dangerous or less addicting version of the 
addictive substance during the acute care phase 
of addiction treatment. These medications may 
function by reducing cravings or withdrawal 
symptoms and/or by reducing the rewards 
associated with the addictive substance. 
Maintenance medications have proven to be 
highly effective in treating a variety of 
manifestations of addiction and in disease 
management. 

Nicotine Replacement Therapy (NRT). NRT, 
when used as directed, provides lower doses of 
nicotine at a slower rate than smoking, 182 
thereby easing nicotine withdrawal symptoms. 183 
For many smokers, it works best as an aid to 
managing nicotine-related cravings when used in 
conjunction with psychosocial therapies. In 
most cases of acute care treatment, a therapeutic 
level of nicotine is reached and then use is 
reduced in order to eliminate the medication 
entirely or reach a maintenance level. 184 
Because most patients who use NRT control 
their treatment regimen on their own, there is a 
risk that the nicotine intake from NRT products 
may be higher than intended for those who do 
not use them as directed or who use them while 
continuing to smoke. 185 

Nicotine gum, lozenges and inhalers and nasal 
sprays deposit nicotine in the bloodstream 
through the lining of the mouth or nose, whereas 



These medications also may be used for an 
extended period of time for disease management. 



the nicotine patch delivers the nicotine through 
the skin. 186 Nicotine gum and lozenges both are 
over-the-counter medications; inhalers and 
sprays require prescriptions. The nicotine patch 
is available both over-the-counter and by 
prescription. 

A meta-analysis f of 1 3 studies found that use of 
nicotine gum can increase significantly smokers' 
chances of quitting for at least six months. 188 
The use of nicotine lozenges nearly doubles the 
chance of achieving continuous abstinence over 
at least a six-month period. 189 Side effects of 
nicotine gum and lozenges include sore throat, 
heartburn, jaw pain and nausea. 190 

Nicotine inhalers come in cartridges which 
release nicotine vapor when puffed that is 
absorbed through the lining of the mouth and 
through the back of the throat. 191 Two meta- 
analyses found that inhaler use can nearly 
double patients' abstinence rate over at least a 
six-month period, relative to those who received 
a placebo. 192 The primary side effect is local 
irritation. 193 Nicotine nasal spray is aerosolized 
nicotine that comes in a spray pump. The 
nicotine is sprayed into the nostrils and absorbed 
rapidly by the nasal membranes. 194 Meta- 
analyses indicate that patients almost double 
their chances of achieving and maintaining 
abstinence at six months with the use of a nasal 
spray versus a placebo. 195 The primary side 
effect of the medication is local irritation. 196 
This form of NRT has the highest potential for 
misuse: 15 to 20 percent of patients report using 
the spray for longer than the recommended 
period and five percent report using a higher 
dose than recommended. 197 

The nicotine patch is available in both single and 
step-down dosages. An eight-week course of 



' The review included only those studies that had 
been published in peer-reviewed journals; however, 
some studies were supported by the pharmaceutical 
industry. Most of the studies included in the analysis 
drew participants from self-selecting populations of 
smokers and, in general, the studies' participants 
received counseling regardless of whether they were 
randomly assigned to receive medication or placebos. 
(This is true of all meta-analyses of tobacco cessation 
interventions reported here.) 



-99- 



treatment is most common; however, one 
study found that an extended course of 
treatment-24 weeks-improves outcomes. 199 
Unlike other forms of NRT, patches do not 
address the behavior of smoking by occupying 
the hands or the mouth or inhaling, but by 
passively and slowly delivering the nicotine. 200 
A meta-analysis of 24 studies found that the use 
of nicotine patches for six to 14 weeks can 
nearly double a smoker's chance of sustaining 
abstinence for at least six months compared to 
placebos. 201 Unlike nicotine gum, there is little 
evidence supporting a connection between 
higher doses and higher efficacy rates, or 
between longer treatments and better 
outcomes. 202 The patch also appears to be 
effective regardless of additional psychosocial 
interventions. 203 The primary side effect of the 
patch is skin sensitivity and irritation. 204 

Contrary to the many controlled studies 
supporting the efficacy of NRT, a population- 
based survey of adult smokers who recently had 
quit smoking casts doubt on its effectiveness in 
smoking cessation and relapse prevention. In 
this study, nearly one-third (30.6 percent) of 
smokers who had quit smoking within the 
previous two years reported having relapsed, 
regardless of whether they used NRT for the 
recommended amount of time and regardless of 
whether the use of NRT was accompanied by 
professional behavioral counseling. While this 
study appears to call into question the efficacy 
of NRT in achieving smoking cessation in the 
general population, 205 it actually underscores the 
fact that NRT is not a comprehensive treatment 
approach to addiction involving nicotine, but 
rather an aid to smoking cessation to be used in 
conjunction with other evidence-based acute 
care and chronic disease management 
approaches. 

Methadone. Methadone is a synthetic opioid 
used as replacement therapy for patients with 
addiction involving opioids. Methadone 
reduces cravings and withdrawal symptoms by 



Methadone can be used in the stabilization, acute 
treatment and disease management/maintenance 
phases of treatment for patients with addiction 
involving opioids. 



stimulating opioid receptors in the brain and 
reduces the rewarding effects of opioids by 
blocking their euphoric effects. 207 Although 
methadone is an opioid, it does not produce the 
same euphoric rush characteristic of heroin or 
oxycodone; its effects are slower and steadier. 208 

Methadone can be taken orally and has a long 
half-life with a slow onset of action. 209 
Methadone is safe when used as directed. It 
allows individuals with addiction involving 
opioids to function relatively normally. 210 
Potential side effects of methadone include 
drowsiness, weakness, headache and nausea, and 
side effects are more likely to occur when 
starting methadone, when switching from 
another narcotic/opioid medication to 
methadone and when the dosage is increased. 211 

Multiple studies have found that participation in 
methadone maintenance treatment (MMT) is 
related to significant reductions in patients' use 
of opioids, criminal behavior, injection drug use, 
needle sharing and risky sexual behavior which 
can increase the risk of HIV and sexually- 
transmitted diseases;' MMT also is related to 
higher treatment retention rates. 212 

Methadone does, however, carry the potential 
for misuse 213 and the risk of overdose. 214 While 
methadone is effective in inhibiting the effects 
of opioids like heroin and morphine, it does not 
appear to inhibit the effects of alcohol or other 
drugs; rather methadone may magnify the 
effects of alcohol and other CNS depressants. 215 
Its use in concert with other addictive substances 
can result in adverse interactions. Methadone 
also may accumulate in the body to a toxic level 
if it is taken too often, or in larger than 
recommended quantities. 216 Because of the risk 
of methadone misuse and its consequences, 
methadone distribution is regulated by strict 
federal and state guidelines. 217 Methadone 
prescribed for addiction involving opioids can 



1 Because methadone does not require intravenous 
injection, methadone users are less likely to engage in 
needle sharing and because they do not need the same 
amount of money to obtain heroin, they are less 
likely to engage in prostitution compared to their 
heroin-using counterparts. 



-100- 



be obtained only through specially-licensed 

* 218 

treatment programs. 

Buprenorphine. Buprenorphine is used in the 
treatment of addiction involving opioids and, 
when used as directed, functions both by 
reducing craving for addictive opioids and by 
easing withdrawal symptoms. 219 At low doses, 
buprenorphine enables patients with addiction 
involving opioids to discontinue their use of the 
drugs without experiencing withdrawal 

220 

symptoms. 

There are two forms of the medication: 
buprenorphine alone (brand name Subutex) and 
a buprenorphine/naloxone combination therapy 
(brand name Suboxone). 221 Approved in 2002 
by the FDA for treating addiction involving 
opioids, Subutex generally is prescribed during 
acute treatment followed by Suboxone for 
maintenance therapy. 222 The naloxone 
component of Suboxone serves to reduce the 
rewarding effects of opioids and helps to prevent 
the misuse of the medication which can occur if 
Suboxone is crushed and then injected or snorted 
to achieve a high. 223 

Buprenorphine must be administered under the 
supervision of a trained physician. 224 It can be 
prescribed by physicians who are certified in 
addiction medicine ' or who complete at least 
eight hours of training 1 ' in the treatment and 
management of addiction involving opioids. 5 225 
Once such training is completed, physicians may 
submit an application to the Substance Abuse 
and Mental Health Services Administration 
(SAMHSA) and receive an identification 



Such restrictions apply only to the use of methadone 
in addiction treatment and not when physicians 
prescribe methadone to treat or manage pain. 
' Through the American Board of Addiction 
Medicine or the American Osteopathic Association. 
* Approved training includes training provided by the 
American Society of Addiction Medicine, the 
American Academy of Addiction Psychiatry, the 
American Medical Association, the American 
Osteopathic Association, the American Psychiatric 
Association or any other organization that the 
Secretary of Health determines is appropriate. 
§ Physicians also must have the ability to provide or 
refer patients to any necessary ancillary services. 



number from the DEA allowing them to 
prescribe the medication. 226 

Buprenorphine provides moderate relief from 
opioid withdrawal and has less risk of misuse 
and overdose than methadone. 227 Another 
advantage to buprenorphine is that it can be 
dosed less frequently than every day and still 
have a beneficial effect, which could help to 
enhance medication adherence. 228 Promising 
results are emerging from preliminary research 
on low-frequency dosing with sustained-release 
formulations of the medication. 229 Despite these 
advantages, buprenorphine has similar side 
effects to methadone and other opioids including 
nausea, vomiting and constipation. 230 

Buprenorphine is equally effective as methadone 
in treating addiction involving opioids. 231 
Research reviews of pharmaceutical treatments 
for addiction involving opioids have found that 
regardless of the dose, buprenorphine is better 
than placebos for ensuring patient retention, 232 
and that higher doses increase the likelihood of 
retention and abstinence relative to lower 
doses. 233 A randomized, controlled trial found 
that patients receiving buprenorphine were 
significantly likelier to have negative urinalyses 
than placebo patients and to report decreased 
cravings for opioid drugs. 234 

Recent research has begun to explore, using 
animal models, the benefits of using 
buprenorphine to treat addiction involving 
methamphetamine. 235 

Oral THC. Preliminary research suggests that 
oral tetrahydrocannabinol (THC), made from the 
psychoactive ingredient contained in cannabis, 
may serve to reduce withdrawal symptoms and 
cravings in patients with addiction involving 
marijuana without producing marijuana-like 
intoxication effects. 236 However, research on 
oral THC and other pharmaceutical therapies for 
use in the treatment of patients with addiction 
involving marijuana, while promising, is in an 
early stage and clinical trials are needed to 
support their use in clinical interventions. 237 



-101- 



Psychosocial Therapies 

Psychosocial treatments for substance addiction 
aim to alter patients' attitudes and behaviors 
with regards to the use of tobacco, alcohol and 
other drugs. These therapies enhance patients' 
skills in coping with life challenges, navigating 
high-risk situations, avoiding substance use 
triggers, controlling cravings and coping with 
lapses. 238 Some therapies focus on enhancing 
patients' motivations to change their substance- 
related behaviors. Other therapies focus on 
helping patients alter their environments in order 
to reduce pressures and cues to use, or provide 
positive or negative reinforcements to help 
patients change their attitudes and behavior. 239 

Psychosocial therapies are critical components 
of almost every treatment regimen, regardless of 
a patient's primary substance of addiction; when 
combined with pharmaceutical treatments they 
enhance treatment efficacy. 240 

As is true of treatments for most other health 
conditions, successful treatment for patients with 
addiction takes into account patients' social and 
financial circumstances as well as their physical 
well-being. And, as is the case for other health 
conditions, not all approaches work equally well 
for all patients; the effectiveness of a particular 
approach depends on patient circumstances such 
as the severity of the addiction, the primary 
substance involved in the addiction, the extent of 
social support and the presence of co-occurring 
disorders; the venue in which the treatment is 
provided; and the nature and dynamics of the 
provider-patient relationship. 241 

The following are brief descriptions of the 
primary psychosocial therapies for addiction 
treatment: 

Motivational Interviewing (MI) and 
Motivational-Enhancement Therapy (MET). 

Motivational techniques capitalize on patients' 
readiness to stop using addictive substances and 
enter treatment by bolstering their motivation to 
change their substance use behaviors. 242 In 
acute care, motivational therapies are employed 
early in the treatment process. They also may be 



used in conjunction with other psychosocial and 
pharmaceutical approaches. 243 

Motivational Interviewing (MI), which can 
occur in inpatient or outpatient settings, is rooted 
in the idea that individuals with addiction often 
feel ambivalent about their substance use and the 
need to change their behaviors. 244 MI 
techniques help patients deal with this 
ambivalence and strengthen their commitment to 
engage in behavior change. 245 Motivational 
Enhancement Therapy (MET) is an adaptation 
of MI* that restricts the intervention to four 
sessions. 1 246 

Both MI and MET have proven efficacy in 
addressing adolescent and adult addiction and 
are cost-effective approaches to treating 
addiction involving nicotine, alcohol and other 
drugs. 247 Two main benefits of MI/MET are 
increased treatment retention and program 
completion, 248 which are associated with 
improved treatment outcomes. 249 A study of 
tobacco cessation among patients who had 
previously had a heart attack found that those 
receiving MI were more likely to achieve 
abstinence after a year than patients who only 
received brief advice about quitting (65.5 
percent vs. 37.0 percent). 1 250 An evaluation of 
MET across five treatment sites found that it 
was associated with greater reductions in alcohol 
and other drug use over a 12-week period than 
standard individual counseling. 5 251 



Both modalities are based on the Transtheoretical 
Model of Behavior Change. 

1 MET was developed for Project MATCH (1997), a 
large study of treatment efficacy that compared the 
effectiveness of three treatment modalities: 12 
sessions of cognitive behavioral therapy (CBT), 12 
sessions of Twelve-Step Facilitation Therapy or four 
sessions of MET. All three groups showed 
significant and comparable declines in alcohol use up 
to three years later. 

* These rates are based on at least one week of 
abstinence corroborated by a family member. 
§ More than 450 individuals with addiction were 
randomly assigned to receive three sessions either of 
MET or standard individual counseling during a one- 
month period. 



-102- 





Motivational Interviewing 


The MI therapist attempts to: 




FvnrpQQ pmnntViv tlirmio'li rpflpptivp 

i^AJJltoo K^lLi^jalLly llllVJllgll 1 1 lltVll V t 




listening; 


• 


Recoonize discrenancies between natients' 




goals or values and their current substance 




use; 


• 


Provide normative feedback on the 




discrepancy between patients' substance 




use and that of their peers; 


• 


Adjust to patient resistance rather than 




oppose it directly; 


• 


Avoid arguments and direct 




confrontations; and 


• 


Support patients' sense of self-efficacy to 




change their behavior. 252 



Cognitive Behavioral Therapy (CBT). 

Cognitive Behavioral Therapy (CBT) involves 
training in social skills, self-control and stress 
management through activities such as role 
playing, behavioral modeling and feedback. 253 It 
is designed to help patients identify, recognize 
and avoid thought processes, behaviors and 
situations that are associated with substance use; 
manage cravings; refuse offers of tobacco, 
alcohol or other drugs; and develop better 
problem-solving and coping skills. 254 

CBT generally is used as a short-term 
intervention and can be tailored both to inpatient 
and outpatient programs via group or individual 
therapy. 255 The therapy has been proven 
effective for adolescents and adults and for a 
variety of manifestations of substance 
addiction. 256 CBT has demonstrated efficacy for 
specific populations such as women with 
addiction and individuals with co-occurring 
disorders.* 257 

Community Reinforcement Approach (CRA). 

The Community Reinforcement Approach 
(CRA) is a multi-phase, intensive 24-week 
outpatient treatment for addiction involving 



CBT may work as well for other populations and 
other substances, but available data largely are 
focused on the ones described here. 



alcohol and drugs other than nicotine. 
Counseling sessions focus on improving family 
relations, learning skills to reduce substance use, 
acquiring vocational skills and developing 
recreational activities and social networks that 
can help to minimize the drive to engage in 
substance use. 259 CRA also assists patients in 
developing communication, problem-solving 
and drug refusal skills. 260 CRA is based on the 
notion that patients must be taught life skills and 
shown that living substance free can be more 
rewarding than a life of addiction. 261 

There is evidence of the effectiveness of CRA 
for treating patients with addiction involving 
alcohol and drugs other than nicotine. 262 
Effectiveness is enhanced when coupled with 
pharmaceutical interventions and abstinence- 
based incentive programs, such as the provision 
of vouchers exchangeable for retail items 
contingent on negative urinalysis results. 263 
Participation in a CRA intervention also has 
shown positive supplementary effects, such as 
increased employment rates and decreased 
criminal involvement. 264 

Contingency Management (CM). 

Contingency Management (CM) is an 
intervention that uses positive and negative 
reinforcement to alter behavior, although 
rewarding positive behavior has been 
demonstrated to be more effective than 
punishing negative behavior. 265 Most CM 
interventions provide patients with vouchers and 
incentives for meeting treatment-related goals 
such as producing a drug- free urine test. 
Incentives can include cash rewards, vouchers to 
purchase desired items or treatment-related 
privileges such as receiving multiple doses of 
medication at one time to avoid having to make 
numerous clinic visits. 266 

The effectiveness of CM has been demonstrated 
for addiction involving nicotine, alcohol, 
marijuana, cocaine, methamphetamine and 
opioids. 267 CM can improve program retention,' 
increase abstinence and help prevent relapse. It 
is most successful when used in conjunction 



1 Improved program retention is associated with other 
positive treatment outcomes. 



-103- 



with other interventions, such as the community 
reinforcement approach (CRA).* 268 

Behavioral Couples/Family Therapy. 

Couples- and family-based treatments aim to 
improve communication and support and reduce 
conflict between couples and within families 
that have a member with addiction. 269 Since 
lack of social and family support often is a 
barrier to treatment enrollment, the support of 
family members is important in helping 
individuals with addiction enter and complete 
treatment. Studies have found family and 
couples therapy to be effective for adolescents 
and adults, men and women and racial/ethnic 
minorities as well as for individuals for whom 
the primary substances of addiction are alcohol, 
marijuana, opioids or cocaine. 270 

A family approach to treatment generally is 
more effective than individual-based programs 
and tends to have higher retention rates than 
other evidence-based interventions. 271 
Combining couples/family therapy with other 
forms of individual-based treatments, such as 
cognitive behavioral therapy (CBT), tends to 
increase treatment effectiveness. 272 



[Addiction] is a family disease and you cannot 
treat an addict without bringing in the family 
and children. 215 

-John Schwarzlose 
Chief Executive Officer 
Betty Ford Center 



Combined Therapies 

Treatment programs that combine 
pharmaceutical and psychosocial treatments 
typically are more effective for individuals with 
addiction than the use of either form of 
intervention alone. 273 



Stronger effects were found when the voucher was 
delivered immediately after the patient met the 
contingency requirement and when vouchers were of 
a higher value. 



Our efforts to date have taught us some 
humbling lessons about addictive diseases, 
namely, that they are complex biopsychosocial 
entities which defy simple "either/or" 
solutions. 214 

-Norman S. Miller, MD 
Professor of Medicine and Psychiatry 
Michigan State University 



Combination therapy is successful for multiple 
reasons. First, the provision of one treatment 
modality tends to enhance compliance with the 
other. 276 For example, medication may help 
patients better tolerate withdrawal symptoms 
that otherwise might have discouraged their 
participation in psychosocial therapy and 
psychosocial therapy might encourage patients 
to initiate and maintain a course of 
pharmaceutical therapy. 277 Medications used in 
conjunction with psychosocial interventions 
have been found to increase patients' likelihood 
of remaining in treatment and maintaining 
abstinence. 278 Second, because there is no one 
treatment that works perfectly for every patient, 
patients who are provided with more than one 
treatment approach have an increased chance of 
success. 279 Third, each modality may produce 
different outcomes, increasing overall success. 
For instance, in the case of smoking cessation, 
pharmaceutical therapy helps patients face 
withdrawal symptoms and maintain abstinence, 
while psychosocial treatments improve 
behavioral, cognitive and coping skills that are 
particularly useful for ensuring compliance with 
treatment and preventing relapse. 280 

Addiction Involving Nicotine. The 

combination of nicotine replacement therapy 
(NRT) and psychosocial approaches to smoking 
cessation increases patients' chances of quitting 
and their chances of achieving long-term 
abstinence. 281 A review of combined therapy 
studies shows that the inclusion of NRT 
produced up to a 15-percentage point increase in 
efficacy rates over psychosocial treatment 
alone. 282 One explanation for the improved 
results of combined therapies for tobacco 
cessation is that NRT is the primary mechanism 
behind patients' initial quitting success while the 
psychosocial therapies give patients the tools 



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they need to avoid relapse over the longer 
term. 283 Forms of pharmaceutical therapy other 
than NRT, such as antidepressants, also can 
enhance the benefits of psychosocial treatment 
for smoking cessation. 284 



Addiction Involving Alcohol. In one study, 
patients with addiction involving alcohol who 
received daily doses of naltrexone were less 
likely than those taking placebos to relapse if 
they also participated in psychosocial therapies, 
including cognitive behavioral therapy (CBT) 
(38 percent vs. 60 percent) or motivational- 
enhancement therapy (MET) (44 percent vs. 56 
percent) over the course of 12 weeks.* 286 
Patients in another study f who received CBT for 
a three-month period were likelier to achieve 
abstinence by the end of the 12-week program if 
they also received daily doses of acamprosate 
(38 percent vs. 14 percent). 287 Another study 
found that six months after treatment 
completion, disulfiram patients in a community 
reinforcement approach (CRA) program spent 
significantly less time drinking than patients 
who used only disulfiram (abstinent 28.3 days 
vs. 8.0 days that month). 288 



CBT patients who took naltrexone spent 
significantly more of their time in treatment abstinent 
from alcohol than any of the other study groups. 
' The study groups were not randomized but matched 
based on gender, age, previous treatment episodes, 
detoxification history and average alcohol intake. 



Addiction Involving Other Drugs. With 
regard to treatment for addiction involving 
opioids, incorporating family therapy into a 
treatment regimen that includes naltrexone 
therapy enhances treatment outcomes with 
regard to medication compliance; abstinence 
from opioids and other drugs during treatment 
and during a year of follow-up; and measures of 
drug-related, legal and family problems at one- 
year follow-up. 289 A meta-analysis of 30 studies 
conducted in outpatient methadone treatment 
settings found that the inclusion of contingency 
management (CM) is related to fewer positive 
urine tests submitted by patients with addiction 
involving opioids. 290 CM also has been found to 
augment naltrexone treatment for addiction 
involving opioids by increasing patients' 
compliance with their treatment regimen. 
Naltrexone patients who received contingency 
management in the form of vouchers in 
exchange for clean urinalyses, on average, 
stayed in treatment longer (7.4 weeks vs. 5.6 
weeks), submitted more opioid- free urine 
samples (18.9 vs. 13.5) and were abstinent 
continuously over longer periods of time (49.1 
days vs. 37.7 days) than patients who received 
naltrexone without a CM component. 291 
Another study found that patients on methadone 
maintenance treatment who received weekly 
community reinforcement approach (CRA) 
sessions demonstrated significantly greater 
reductions in drug problem severity 1 than 
patients who received standard methadone 

292 

maintenance services. 

Other research finds that cognitive behavioral 
therapy (CBT) patients who received daily 
doses § of modafmil versus a placebo provided 
significantly more clean urine tests (42.3 percent 
vs. 24.0 percent) and were likelier to achieve 
abstinence from cocaine over at least a three- 
week period (33 percent vs. 13 percent). 293 

Addiction Involving Poly-Substances. 

Research on the best methods of treating 
individuals with addiction involving multiple 
substances is limited. One study found that 
methadone maintenance patients with addiction 



As measured by the Addiction Severity Index. 
400 mgs. 



A Spectrum of Smoking Cessation 
Treatments 

Smokers of less than five cigarettes per day 
will have a good chance of success in quitting 
by choosing a quit date, getting rid of tobacco 
and using freely-available counseling/support 
services. Smokers of 6-14 cigarettes per day 
probably are moderately dependent and will 
benefit from an approved smoking cessation 
aid (nicotine patch, gum, lozenge, inhaler or 
nasal spray, bupropion, varenicline). Smokers 
of 15 or more cigarettes per day probably are 
highly dependent and will benefit from more 
intensive counseling and possibly combination 
pharmaceutical therapy. 285 



-105- 



involving both opioids and cocaine fared better 
if they were randomly assigned to receive 
bupropion versus placebos and CM versus no 
psychosocial intervention. 294 Other research 
points to the potential utility of combining an 
antidepressant* with CM for patients with 
addiction involving opioids and cocaine who are 
maintained on buprenorphine. 295 Patients who 
received this combined therapy provided more 
drug-free urine samples during treatment and 
achieved a period of continuous abstinence that 
was, on average, twice as long as patients with 
addiction involving opioids and cocaine who 
were in the control conditions. f 296 Preliminary 
evidence also suggests that daily doses of 
naltrexone 1 combined with CBT may be 
effective for treating addiction involving alcohol 
and cocaine, particularly among men. 297 

Nutrition and Exercise 

A healthy nutrition and exercise regimen can 
mitigate the symptoms of withdrawal, enhance 
the effects of evidence-based treatment and help 
sustain successful treatment outcomes. 298 
Furthermore, because different addictive 
behaviors can share common causes, patients in 
treatment for addiction involving nicotine, 
alcohol or other drugs may substitute unhealthy 
foods in an attempt to satisfy addictive 
cravings. 299 This is particularly evident in the 
common case of weight gain following smoking 
cessation. As such, a comprehensive approach 
to addiction treatment includes interventions 
aimed at ensuring good nutrition and exercise. 

Nicotine, alcohol and other drug use also disrupt 
normal body functioning— resulting in nutritional 
deficiencies, dehydration or electrolyte 
imbalance-and often lead to unhealthy lifestyle 
changes such as poor diet and irregular eating 
habits. 300 Providing patients in addiction 
treatment with nutritional programming may 
help them to reverse some of the damage that 
smoking, drinking and using other drugs can 
inflict on their bodies. The improvements in 



desipramine 
' Who took placebos combined with CM, 
desipramine without CM or placebos without CM. 
* 150 mg. 



general health and mood that may result from 
healthy eating habits also could help patients 
maintain their abstinence. 301 

Some individuals in treatment attempt to 
compensate for the lack of alcohol, for example, 
by consuming significant amounts of sugar and 
other carbohydrates which may increase 
serotonin 5 levels. 302 A healthier approach, 
according to one theory, suggests that eating 
foods that are rich in the precursors of the 
neurotransmitters which are depleted when a 
substance user abstains will reduce cravings for 
those substances and facilitate the treatment 
process. 303 These include protein-rich foods 
such as meat, fish, dairy products and nuts. 304 

Exercise also stimulates brain cells that reinforce 
dopamine -related reward pathways. 305 This 
reinforcement may allow substance users to 
experience pleasurable effects from exercise 
which potentially could reduce their substance- 
related cravings. 306 Exercise generally is 
beneficial in reducing symptoms of depression 
and anxiety that often co-occur with and 
contribute to addiction. 307 Another theory 
regarding the utility of exercise in a 
comprehensive treatment program is that as 
individuals develop a mastery of exercise 
techniques, they increase their self-efficacy—the 
belief that one can master new skills— which can 
be applied to disease management strategies. 308 
Patients who exercise in group settings also may 
benefit from social support networks and social 
interactions that do not involve tobacco, alcohol 
or other drug use. 309 

Exercise moderates the effects of nicotine 
withdrawal symptoms including reductions in 
cravings, negative mood, 310 sleep disturbances 311 
and tension. 312 One study found that exercisers 
in a smoking cessation program were twice as 
likely as those who did not exercise to 
demonstrate continual abstinence by the end of 
the three-month program, and three and 12 
months following treatment completion. After a 
year, exercise participants were 36 percent less 



5 A neurotransmitter involved in mood, emotion, 
sleep, appetite and some aspects of addiction. 



-106- 



likely than those who did not exercise to have 
relapsed. 313 

Chronic Disease Management 

Although the reasons are not yet clear, some 
individuals may experience one episode in 
which their symptoms meet clinical diagnostic 
criteria for addiction and be non-symptomatic 
thereafter. 314 In many cases, however, addiction 
manifests as a chronic disease-a persistent or 
long-lasting illness— which requires ongoing 
professional treatment and management. 315 This 
may be due to a preexisting brain dysfunction or 
to changes that occur in the brain in response to 
repeated exposure to addictive substances which 
increase the vulnerability of the individual to 
relapse, even after cessation of substance use. 316 

All chronic diseases— regardless of whether they 
are genetically based, driven by biological or 
environmental influences or originate from some 
combination of these factors-require long term, 
evidence-based medical management of the 
disease by qualified health professionals and 
may include pharmaceutical and/or psychosocial 
therapies as indicated, to assure that patients 
remain symptom free and that co-occurring 
health conditions and the patient's nutrition and 
exercise requirements are addressed. 317 

Chronic disease management can improve 
patient functioning, suppress symptoms, prevent 
the development of additional diseases or co- 
occurring conditions and reduce relapse. 318 

Relapse can result from a wide range of factors 
including cravings and withdrawal symptoms; 
interpersonal conflict, peer pressure and other 
stressors; and the patient's emotional state, 
motivation level, self-efficacy and ability to 
cope with high-risk situations. 319 Recent 
research also points to individual differences in 
brain structure as a risk factor for relapse: 
patients in treatment for addiction involving 
alcohol who had reduced volumes of gray 
matter* in the regions of the brain associated 



Gray matter volumes were measured via magnetic 
resonance imaging (MRI). Gray matter is considered 
a reliable indicator of neural count and functionality. 



with impulse control and cognitive function 
were more likely to relapse after a shorter period 
of time than those with higher volumes of gray 
matter in these brain regions. 320 Yet another 
obvious but rarely considered factor that may 
contribute to relapse risk is that the treatment the 
patient received simply was inadequate, either in 
terms of the type of intervention provided or the 
length or intensity of the treatment. 321 

Chronic disease management, as it applies to 
addiction treatment and relapse prevention, 
seeks to address and prevent those factors that 
increase the likelihood of relapse by ensuring 
that treatment delivery is effective and that 
personal, psychological and environmental risk 
factors for relapse are addressed and 
mitigated. 322 Specifically, physicians 
supervising addiction treatment should assess 
the need for chronic disease management and 

323 

ensure continuing care. 

Medically Supervised Disease Management 

Health care providers are optimally situated to 
provide clinical disease management. 324 
Following acute treatment, the disease 
management process is critical to help maintain 
health and prevent relapse. 325 

Patients who have received acute treatment for 
addiction may require maintenance medications 
such as methadone, buprenorphine, naltrexone, 
disulfiram or NRT to prevent relapse. 326 Since 
many patients with addiction have co-occurring 
health conditions that may complicate their 
treatment or exacerbate the risk of relapse, 
medical professionals should carefully supervise 
and coordinate treatment for all conditions. 327 
Medical professionals supervising patient care 
also may perform toxicology screens to monitor 
patients' substance use following acute 
treatment and modify clinical interventions 
accordingly. 328 

Medical professionals also should supervise the 
psychosocial interventions that patients receive 
following acute addiction treatment. 
Psychosocial therapy often is a critical 
component of relapse prevention. 329 
Collaborating with other health professionals, as 



-107- 



needed, physicians should work to educate 
patients about the precipitants of cravings and 
relapse and help them to cope adaptively with 
the associated psychological and environmental 
risk factors. 



The Physician Health Program 

An addiction treatment model that provides 
effective long-term disease management is the 
Physician Health Program (PHP) established by 
state medical societies and licensing boards to treat 
physicians who have addiction. 330 Today, all 50 
states and the District of Columbia have a PHP. 331 
The PHP assists the participating physician in 
finding clinical treatment services, 332 provides case 
management of individuals undergoing treatment 
and maintains relationships with the authorized 
treatment facilities that evaluate and treat referred 
physicians. 333 Contingency management in the 
form of negative consequences for violating its 
terms (e.g., losing one's license to practice 
medicine, malpractice suits, disciplinary actions 
from hospital boards) is a critical part of the 
program. 334 PHPs must have the oversight of a 
medical director; some have an MD on staff who 
serves as a medical consultant. 335 

Treatment managed by a PHP is more intense and 
lasts longer than that for the general population, 
with three to six months spent in structured therapy 
followed by five years of contingency management, 
and it includes pharmaceutical therapy, 
psychosocial interventions and nutrition and 
exercise counseling. 336 PHPs also typically have a 
mutual support program component. 337 Long-term 
monitoring is employed to reduce relapse: when 
relapse or signs of possible relapse occur, the 
reaction is therapeutic, not punitive. 338 Physicians 
who relapse tend to improve again after a treatment 
adjustment. 339 

More than 80 percent of physicians who participate 
in PHPs return to work and remain substance free 
for a minimum of five years after receiving 
treatment. 340 Seventy-one percent of participating 
physicians retain their medical license and are 
employed after five years. 341 

Key elements of the PHP program that appear to 
contribute to its success and that are replicable in 
the general population include high intensity care 
for an extended duration and the inclusion of long- 
term monitoring and disease management. 342 



Case Management 

Many of the activities involved in chronic 
disease management and oversight can be 
performed by professionally-trained case 
managers working in a variety of settings such 
as physicians' offices, hospital or out-patient 
addiction treatment programs, justice facilities 
or social service agencies. They should, 
however, work under the supervision of a 
trained physician and other medical 
professionals. 343 



A Case Management Approach: 
Recovery Management Checkups 

Recovery Management Checkups (RMC)— in 
which patients are contacted, evaluated and 
linked to additional support services including 
those that address co-occurring conditions-have 
been shown to be an effective approach to 
chronic disease management by helping patients 

i • "S44 

engage in and stay in treatment. 

Research finds that adolescents and adults in 
addiction treatment who receive RMCs-based 
on a method that involves locating individuals 
for checkup, assessing eligibility for 
intervention, linking individuals to treatment 
services, engaging participants in treatment and 
retaining participation for at least 14 days in 
residential treatment or seven days in intensive 
or regular outpatient treatment— demonstrate 
higher levels of treatment participation and 
abstinence rates and reduced time to 
readmission for treatment following relapse. 345 
Patients receiving such checkups were 
significantly likelier than patients receiving 
usual care to return to treatment (55 percent vs. 
37 percent), do so sooner (384 days earlier) and 
to be abstinent (480 days vs. 430 days) over a 
two-year follow-up. 346 



Professional case managers can help to navigate 
and coordinate resources within the fragmented 
health care system and ensure that patients 
receive the services they need to keep addiction 
symptoms in check. 347 The role of the case 
manager is to link patients to the health and 
social services appropriate to their specific 
needs, ensure that patients follow through with 
referrals, help patients identify and access a 



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variety of additional support programs including 
family and peer support and auxiliary services, 
provide educational materials on relapse 
prevention and promptly intervene in the case of 
relapse. 348 Monitoring the course of a patient's 
treatment and connecting patients with services 
when they are needed are common public health 
approaches to addressing chronic illnesses. 349 



Case management is associated with an 
increased chance that people with addiction will 
access treatment for relapse, remain in treatment 
for a longer period of time 350 (which is 
associated with better treatment outcomes), 
utilize support services 351 and demonstrate 



improved social outcomes.* 352 A meta-analysis 
of case management for patients in treatment for 
addiction involving alcohol or drugs other than 
nicotine found that case management can 
improve patients' family and social 
relationships, living situations and health. 353 

Support Services 

Comprehensive care for patients with addiction 
requires not only proper assessment, 
stabilization, acute care and chronic disease 
management, but support services as well. 
These may include: 

• Mutual support programs to bolster disease 
management efforts and avoid the 
recurrence of disease symptoms; and 

• Auxiliary support services to address legal, 
educational, employment, housing, 
parenting and child-care issues that may 
impede disease management. 356 

Health care providers are optimally situated to 
facilitate links to these support and auxiliary 

357 

services. 

Mutual Support Services 

Mutual support programs, sometimes referred to 
as self-help groups, can be a significant part of a 
comprehensive approach to caring for a patient 
with addiction. In fact, for many people with 
addiction, these programs have been the main 
help available to them and have been both 
lifesaving and critical to helping them manage 
their disease. 358 These programs allow 
individuals with addiction to seek and provide 
social, emotional and informational support 
within a group of their peers. Participation in 
these programs can increase the chances of 
achieving and maintaining abstinence as well as 



In one study, veterans with addiction involving 
illicit drugs who were assisted by case managers 
experienced a larger increase in the number of days 
they spent gainfully employed than their peers who 
went unassisted which, in turn, was associated with 
lower rates of substance use, incarceration and arrests 
resulting in convictions. 



An Example of an Effective Case 
Management Program for Women 

CASASARD SM is a welfare demonstration 
program for mothers in Essex and Atlantic 
counties in New Jersey who have addiction. The 
program is designed to get women engaged in 
treatment and employment services, help them 
become sober and move successfully to stable 
employment. CASASARD SM uses an intensive 
case management approach to provide services 
for these women. 

CASA Columbia's research has found that 
women with addiction involving alcohol or other 
drugs (excluding nicotine) who receive income 
assistance through CASASARD SM were more 
likely to initiate treatment (66.5 percent vs. 50.3 
percent) and complete their programs (43.5 
percent vs. 22.7 percent) if they were provided 
with case management services rather than 
standard care. Looking at abstinence as one 
outcome measure, over a 12-month post-referral 
period, women participating in the 
CAS ASARD SM program had a 64 percent higher 
monthly abstinence rate than their peers in the 
standard care program, and were likelier to have 
remained completely abstinent by the end of the 
12-month period (41 percent vs. 25 percent). 354 
After another 12 months, the abstinence rate 
among CASASARD SM participants had 
increased to 47 percent while the abstinence rate 
among non-participants remained relatively 
unchanged (24 percent). 355 



-109- 



help patients reduce their substance-related 
problems. 359 They are incorporated into many 
formal treatment programs, can be an important 
part of chronic disease management and 
constitute the most frequently-accessed resource 
among people with addiction involving alcohol 
and other drugs and related problems. 360 
National data indicate that an average of five 
million people ages 12 and older attend an 
alcohol or other drug use mutual support group 
each year. Slightly less than half (45.3 percent) 
of the attendees participated in support groups 
for addiction involving alcohol; 21.8 percent 
participated in support groups for addiction 
involving other drugs and 33.0 percent 
participated in support groups for co-occurring 
addiction involving alcohol and other drugs.* 361 

Although there are many types of mutual 
support programs, most have many 
characteristics in common: 362 

• Group members share the same problem or 
status; 

• Groups are run using self-directed 
leadership; that is, members, rather than an 
outside governing figure, are in charge of 
the program; 

• Group members share their experiences and 
lessons learned; 

• Members share the goal of changing some 
aspect of their personal behavior; 

• Reciprocal helping is the norm; 

• Members participate on a voluntary basis; 
and 

• Programs may accept donations but do not 
charge for membership. 363 

Some organizations focus more on providing 
fellowship, information or self-acceptance while 
others attempt to address the origin of 



Comparable data on rates of participation in 
Nicotine Anonymous are not available. 



participants' addiction problems. Programs 
also vary in terms of the methods used to 
address addiction, the extent to which there is an 
emphasis on spirituality or religion, whether 
members are encouraged to participate in 
political advocacy, ' whether friends and family 
members are included in group meetings, the 
extent to which the group facilitates connection 
with treatment professionals working in an 
advisory role* and whether the program accepts 
external funds. 365 

The 12-step groups, such as Alcoholics 
Anonymous (AA) and Narcotics Anonymous 
(NA) are some of the best known and most 
widely available mutual support programs. 5 366 
They provide participants with 12 steps to 
follow during the process of recovery. 367 These 
programs generally begin with the acceptance of 
one's addiction and- thro ugh a process of self- 
exploration— participants take action to make 
changes toward recovery. 368 

Other core components of these programs are 
taking responsibility for the recovery process, 
sharing personal experiences, recognizing the 
existence of a higher power, helping others and 
lifetime commitment to the program. 369 Outside 
of the group meetings, sponsorship" plays an 
important role in most 12-step programs. Each 
new group member finds a sponsor to serve as a 
role model, program guide and first line of 
support in the case of a potential or actual 
relapse. 370 It is estimated that AA, the oldest 



' e.g., unlike organizations such as Alcoholics 
Anonymous (AA) and Narcotics Anonymous (NA) 
which require anonymity, the Faces and Voices of 
Recovery organization seeks to organize and 
mobilize individuals with histories of addiction, their 
families and friends in public policy advocacy 
efforts. 

* Professionals may work in an advisory role or they 
may serve as guest lecturers. 
§ There also are 12-step programs for individuals 
dealing with gambling and other types of addiction, 
and with a family member's or friend's addiction, 
such as Al-Anon and Alateen. 

** Sponsors typically have completed at least one year 
of abstinence with the program and are of the same 
sex as the new member (or a different sex for gay 
members). 



-110- 



and best known of the 12-step programs, has 
more than 2,000,000 members in more than 
1 14,000 groups in more than 180 different 

371 

countries. 

Other examples of mutual support programs that 
do not follow the traditional 12-steps approach 
and that are secular in nature include SMART 
Recovery (Self-Management and Recovery 
Training), 372 Secular Organizations for Sobriety 
(SOS), Women for Sobriety and LifeRing 
Secular Recovery. 373 Groups vary based on the 
population they serve. 374 

Participation in mutual support programs- 
including 12-step and secular-based programs- 
has been associated with improved 
psychological functioning, reduced substance 
use and reduced health-care costs and 
utilization. 375 However, there are 
methodological limitations to the effectiveness 
studies that examine mutual support programs, 
restricting the extent to which their ability to 
curb substance use and help manage addiction 
can be determined. 376 Most are not randomized 
controlled studies, research on the programs is 
difficult to conduct due to the anonymous nature 
of group membership 377 and there may be an 
inherent bias in the research in that AA and 
other 12-step groups may attract patients who 
are more motivated to change. 378 Despite the 
limited empirical evidence demonstrating the 
effectiveness of mutual support programs like 
AA, anecdotal evidence of their effectiveness 
abounds. 379 

One finding that emerges consistently from the 
available research is that patients who had been 
in addiction treatment and then followed up with 
involvement in mutual support programs fare 
better than those who do not. 380 A study that 
followed treatment patients with addiction 
involving alcohol for three years found that 
those who were more involved with mutual 
support programs were likelier than other 
patients to be abstinent the next year. Mutual 
support program members who were not 
abstinent the year following group participation 



Including, but not limited to, AA, SMART 
Recovery and Women for Sobriety. 



still drank less on the days that they did consume 
alcohol. 381 Other research finds that those who 
attend AA or another 12-step group following 
treatment have about twice the rate of abstinence 
as those who do not participate in these mutual 
support programs. 

Reviews of the research on the effectiveness of 
mutual support programs suggest that it may not 
be the specific content of the programs or their 
processes that are associated with positive 
outcomes, but rather the fact that they provide 
free, long-term and easily-accessible exposure to 
people and messages that support recovery, 383 
which is a key element of chronic disease 
management. 384 

Twelve Step Facilitation. Twelve Step 
Facilitation (TSF) is a formalization and 
professionalization of the 12-step mutual support 
model which involves a brief, structured and 
manual-driven approach implemented over the 
course of 12 to 15 sessions by a trained 
counselor or treatment provider. 385 During these 
sessions, providers will advocate abstinence, 
explain the basic concepts of the 12-steps and 
actively support and facilitate the patient's 
involvement in 12-step programs. TSF can be 
implemented in an individual or group format or 
including the patient's significant other. It has 
been used in acute treatment and as a method of 
providing support services for chronic disease 
management. 386 

TSF has been used to address addiction 
involving alcohol, 387 marijuana and 
stimulants. 388 Evaluations of TSF are limited; 
however, several studies have found it to be 
comparable in effectiveness to psychosocial 
treatments such as CBT and MET. 389 It is listed 
in SAMHSA's National Registry of Evidence- 
based Programs and Practices 390 and as an 
evidence-based approach by the National 
Institute on Drug Abuse (NIDA). 391 

Residential Programs. Some mutual support 
approaches, such as the Therapeutic Community 
(TC) model, are residential and incorporate 
elements of treatment. Other residential 
programs such as recovery homes or sober living 
houses provide mutual support only. These 



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programs are non-professional, generally low- 
cost communal homes that provide supportive, 
substance-free living environments to 
individuals attempting to establish or maintain 
sobriety. 392 Homes may be democratically run 
or hierarchically structured with house managers 
in charge of other residents. Typically, 
participation in additional aftercare services is 
encouraged or required. 393 

Therapeutic Communities. The TC model, used 
primarily but not exclusively with the justice 
population, is a highly structured residential 
program that requires a long-term commitment 
(six to 24 months). 394 It is based on mutual 
support principles and incorporates behavior 
modification techniques, education classes and 
residential job duties. 395 This approach aims to 
re-socialize the patient to a substance-free, 
crime-free lifestyle through peer influence, 
personal responsibility and skill training. 396 TC 
participants commonly include individuals with 
relatively long histories of addiction, 
involvement in serious criminal activities and 
significantly impaired social functioning. 397 The 
mutual support aspect of TCs operates on a 
hierarchical basis; patients who have been 
involved in the program longer provide support 
and serve as role models for newer patients. 398 

A large, national study found that patients 
enrolled for at least 90 days in a TC 1 were 
significantly less likely to have used cocaine (28 
percent vs. 55 percent), tested positive for drug 
use (19 percent vs. 53 percent), reported daily 
alcohol use (9 percent vs. 15 percent) or have 
spent time in jail (24 percent vs. 54 percent) a 
year after program participation than those who 
spent fewer than 90 days in the program. 399 The 
year following successful TC completion 
showed lasting effects along several indicators 
compared to the year prior to TC entry: the rate 
of weekly cocaine use fell from 66.4 percent to 

22.1 percent; weekly heroin use, from 17.2 
percent to 5.8 percent; heavy alcohol use, from 

40.2 percent to 18.8 percent; illegal activity, 
from 40.5 percent to 15.9 percent; less than full- 



Not defined. 
* Long-term residential programs, most of which 
were TCs. 



time employment, from 87.6 percent to 77.0 
percent; and reported suicidal thoughts, from 
23.6 percent to 13.2 percent. 400 

For patients with co-occurring mental health 
disorders, a Modified Therapeutic Communities 
(MTC) model takes into account patients' 
psychiatric symptoms, 1 potential cognitive 
impairments and reduced levels of functioning 
due to substance use, including poor control 
over urges and short attention spans. MTCs are 
more flexible, less intense and more 
individualized than standard TCs. 401 

Sober Living Houses. Sober Living Houses 
provide a substance-free living environment for 
individuals with addiction involving alcohol, 
illicit drugs and controlled prescription drugs. 
No formal treatment services are provided but 
residents are mandated or strongly encouraged 
to participate in mutual support programs and 
must comply with house rules which include 
maintaining abstinence, paying rent, 
participating in house chores and attending 
house meetings. 402 Failure to comply with these 
rules results in dismissal from the home. 403 

One study of the combination of participating in 
a sober living house and receiving outpatient 
treatment interviewed participants within their 
first week of entering the houses and again at 
six-, 12-, and 18-month follow-ups. § The study 
found significant improvements over time on 
measures of alcohol and other drug use, arrests 
and employment. 404 

The Oxford House Model. Oxford House, 
founded in 1975, is one of the most prevalent 
and well-studied examples of communal-living 
environments of this nature. 405 Unlike sober 
living houses, they encourage but never mandate 
participation in mutual support programs. 406 
Typically, eight to 1 5 residents of the same sex 
live in each home. Most recently have received 
detoxification or some form of treatment and 
many have been homeless or spent time in jail at 



1 Although care is not medically-supervised. 
§ The average length of stay in the sober living 
houses was over five months but there was 
considerable variation. 



-112- 



some point in their lives. Homes are run 
independently by the residents; there are no on- 
site professional treatment providers. The 
homes are supported financially by residents 
who are required to pay the rent on time and 
maintain their sobriety. Contrary to a chronic 
disease management approach, members who 
relapse are expelled immediately from the house 
and must demonstrate 30 days of sobriety before 
reapplying for residence. 408 Residents are 
expected to attend weekly meetings where house 
issues are discussed and where they are 
encouraged to attend mutual support 

409 

programs. 

One study found that two years after completing 
treatment and entering an Oxford House, current 
and former residents were more successful at 
decreasing their use of alcohol and other drugs 
than those who completed treatment but simply 
received standard aftercare referrals to outpatient 
programs or self-help groups. 410 Over that 
period, those who lived in an Oxford house were 
less than half as likely as those who received 
usual care to use any substance (31.3 percent vs. 
64.8 percent), less likely to be currently facing 
criminal charges (0.0 percent vs. 5.6 percent) 
and more likely to be employed (76.1 percent vs. 
48.6 percent) two years later. Only 15.6 percent 
of participants who had lived in an Oxford 
House for at least six months relapsed after two 
years and residents ages 36 and younger 
demonstrated a two-year relapse rate of only 6.7 

411 ~ ' 

percent. 

Auxiliary Support Services 

Patients who complete treatment successfully 
may find themselves facing relapse due to the 
anxiety of coping with other health problems, 
unemployment, child care, homelessness, 
criminal justice and other social problems. 412 
Matching patients with the services necessary to 
address these problems decreases the risk of 
relapse. 413 



New houses often are started with federal or state 
loans stemming from the 1988 Anti-Drug Abuse Act; 
the loans are paid back by the residents. 



According to data from a national multi-site 
study of a variety of treatment modalities, the 
majority of treatment patients' perceived a need 
for auxiliary support services including family 
counseling services (70.9 percent), 
supplementary medical care (63.5 percent), 
mental health care (63.4 percent), housing (63.0 
percent) and vocational services (61.4 
percent). 414 (Figure 5.A) 



Figure 5.A 

Addiction Treatment Patients' Perceived 
Needs for Auxiliary Services 





70.9 


63.5 


63.4 


63.0 


61.4 























Family Supplementary Mental Health Housing Vocational 
Counseling Medical Care Care Services 



Source: CASA Columbia analysis of Friedmann et al (2004). 



The perceived needs for supplementary medical, 
including mental health, care underscore the 
historic disconnect of addiction treatment from 
medical care. Individuals who had their 
perceived needs for vocational and housing 
services met showed significant reductions in 
illicit drug use.' 415 

Evidence from a smaller study also 
demonstrated that matching treatment patients 
with services they need can decrease the severity 
of their substance use.* Six-months after 
enrolling in the study, patients who reported a 
need for housing services and had their needs 
matched experienced a greater reduction in their 
substance use severity score compared to 
patients with housing needs who were not 
matched to services (50 percent vs. 23 percent 



' Patients' needs were determined by their rating of a 
service as "somewhat or very important." Because 
patients were not randomly assigned to receive 
services, the reductions in illicit drug use cannot be 
linked directly to having their perceived service 
needs met. 

* As measured by the Addiction Severity Index. 

-113- 



reduction). Similarly, patients who reported a 
need for child care services and had their needs 
addressed experienced a greater reduction in 
their substance use severity score compared to 
patients with child care needs who were not 
matched to needed services (45 percent vs. 20 
percent).' 416 

The Use of Technology in Addiction 
Treatment and Disease 
Management 

An emerging approach to identifying, treating 
and managing addiction-the utilization of online 
computer tools and other technology-based 
interventions to enhance access and delivery— is 
showing some promising results. 417 These 
include telephone contact with treatment 
providers and e-mail, text messaging, 
smartphone apps and online support groups. 418 

Online approaches that employ evidence-based 
practices via Web sites or tele- or video- 
conferencing offer key advantages. They can 
provide psychosocial therapies to patients at 
lower cost than traditional face-to-face 
approaches. 419 They allow patients who live far 
from specialty treatment providers or who lack 
resources to access psychosocial therapies or 
supplemental services in a convenient manner. 420 

Researchers are just beginning to investigate the 
utility of technology-based services for patients 
with addiction. While most existing studies are 
methodologically weak or flawed, 421 a 
randomized controlled trial of a digitally- 
delivered smoking cessation intervention found 
significantly higher long-term abstinence rates 
compared to a control group receiving only a 
self-help booklet (22.3 percent vs. 13.1 
percent). 422 Another randomized control study 
found that patients enrolled in a methadone 
maintenance program who participated in 
Internet-based group therapy sessions reported 



There was a 41 percent reduction among patients 
who never reported needing the services. Patients 
were not randomly assigned to receive services. 
' There was a 3 1 percent reduction among those who 
never reported needing the service. 



greater satisfaction with the program than 
patients who participated in traditional, face-to- 
face group therapy sessions; reductions in 
positive drug urine tests during the six-week 
study were comparable between the two groups, 
suggesting that Internet-based therapy may be an 
effective treatment tool. 423 A recent study found 
that a smartphone-based support system shows 
potential for preventing relapse in addiction 
involving alcohol; 424 however, further research 
is needed on this particular program and, more 
generally, on the outcomes of technology-based 
services and how they compare to traditional 
service delivery methods. 425 

Concerns about technology-based services 
include the risks to privacy and confidentiality 
of information transmitted over the Internet, 
safety and efficacy, and issues of licensing 
posed by treatment delivered across state 
lines. 426 

Public Attitudes about Addictive 
Substances and the Need for 
Addiction Treatment 

Although the American public appears to be 
supportive of assuring that individuals with 
addiction receive effective addiction treatment, 
the view of most individuals about the relative 
need for treatment for individuals who use 
addictive substances and what constitutes 
effective treatment does not match the science of 
best practices. 

Perceptions of the Relative Need for 
Treatment Based on Substance of 
Addiction 

CAS A Columbia's NAB AS found significant 
differences in respondents' views of the type and 
extent of substance use that indicates a substance 
use problem and the need to seek treatment. 
Public perceptions do not reflect the continuum 
of substance use or distinguish between risky 
use and the need for intervention versus 
addiction and the need for treatment: 

• The majority of respondents reported that 
any use of the illegal drugs heroin (84.0 



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percent), cocaine (76.0 percent) or 
methamphetamine (73.9 percent) indicates 
that the user has a serious problem and 
should seek treatment. 

42.5 percent thought that any misuse of a 
controlled prescription drug is a serious 
problem requiring treatment; 29.6 percent 
thought that daily or more than daily misuse 
of these drugs is serious enough to require 
treatment. 

35.8 percent felt that any use of marijuana 
indicates that the user has a serious problem 
and should seek treatment; the same amount 
(35.9 percent) thought that daily or more 
than daily use of marijuana is a serious 
problem that requires treatment. 



complete abstinence should be the main goal of 
treatment for individuals with addiction 
involving illicit drugs (65.7 percent), alcohol 
(60.0 percent), tobacco (50.1 percent) or 
controlled prescription drugs (47.1 percent). 
Whereas the next most common response for the 
goal of addiction treatment was that the goal 
should be set by the patient, a small but 
significant proportion indicated that reduced use 
should be the primary goal; this was particularly 
true for addiction involving prescription drugs,' 
tobacco and alcohol, but less so for addiction 
involving illicit drugs. A focus solely on 
reducing the negative consequences of substance 
use (the "harm reduction" approach) rather than 
reducing or eliminating use was endorsed by 
fewer than five percent of the respondents as a 
main goal of treatment. 428 (Figure 5.B) 



78.0 percent reported 
that alcohol use is a 
serious problem 
requiring treatment if 
it occurs daily or 
more than daily; 6.8 
percent reported that 
any drinking is a 
serious problem 
requiring 



treatment. 



427 



49.5 percent felt that 
smoking was a 
serious problem 
requiring treatment if 
it occurred on a daily or more than daily 
basis; 24.3 percent reported that any 
smoking is a serious problem requiring 
treatment. 



Figure 5.B 

Public Perceptions of the Goals of Treatment 




60.0 



50.1 



n 



47.1 



29.7 



21.1 



"114.6 



7.6 



22.7 



20.! 



3.5 



Illicit Drugs 



Alcohol 



Tobacco 



Prescription Drugs 



i Complete 
Abstinence 



i Goal Set by 
Patient 



i Reduced Use 



1 Fewer Negative 
Consequences 



Source: CASA Columbia National Addiction Belief and Attitude Survey (NABAS), 2008. 



Perceptions of the Goals of Treatment 

From a medical perspective, the goal of 
addiction treatment would be to restore and 
maintain health and eliminate or reduce risky 
behavior that threatens health and safety. Most 
respondents to the NABAS indicated that 



In the NABAS survey, respondents were asked 
which of the following they thought should be the 
main treatment goal for someone with addiction 



involving tobacco, alcohol, illicit drugs and 
prescription drugs: complete abstinence, reduced 
use, fewer negative consequences from use, or that 
the goal should be set by the patient. 
' For prescription drugs, reduced use was a more 
common response (22.7 percent) than that the goal 
should be set by the patient (20.8 percent). 



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Perceptions of the Types of 
Interventions that Constitute Treatment 

Although a wide range of psychosocial and 
pharmaceutical therapies are available to 
treat addiction, 60.1 percent of respondents to 
the NABAS spontaneously offered mutual 
support programs such as AA or NA as a 
"treatment" intervention when asked what 
kinds of treatment come to mind when they 
think about treatment for addiction. This is 
despite the fact that a mutual support 
program, while a very helpful resource to 
many individuals with addiction, is not an 
evidence-based treatment for the disease. 
Forty percent (39.9 percent) mentioned a 
hospital visit, 1 1.7 percent mentioned residential 
rehabilitation clinics and 10.4 percent mentioned 
outpatient treatment as what comes to mind 
when they think of addiction treatment (although 
these are treatment venues, not treatments 
approaches). Although only 1 1.6 percent 
mentioned the utilization of prescription 
medications for treating addiction (Figure 5.C), 
a separate question found that 54.7 percent of 
respondents (46.8 percent of those with a history 
of addiction) stated that it is good that there are 
medicines to treat addiction because addiction is 
a medical condition that medicine can help. 
Perhaps reflective of a lack of knowledge about 
effective treatment for addiction, 38.3 percent of 
respondents (48.6 percent of those with a 
history of addiction) indicated it is not good 
news that there are medicines to treat 
addiction because treating addiction with 
medication only serves to replace one 
addiction with another 



429 



Some individuals with addiction may not 
access appropriate treatment because of the 
belief that the use of pharmaceutical 
treatments, such as methadone, to treat 
addiction is contrary to the abstinence-based 
perspectives of addiction treatment espoused 
by many mutual support/ 12-step programs. A 
recent study found that adherence to such 
beliefs leads many heroin users to underutilize 
methadone maintenance therapy despite their 
knowledge of its effectiveness. 430 



Figure 5.C 

Public Perceptions of the Types of Interventions 
that Constitute Treatment 



60.1 



39.9 



11.7 



11.6 



10.4 



Mutual Support Hospital Visit Residential Prescription Outpatient 
Program Rehab Clinic Medication Treatment 

Source: CASA Columbia National Addiction Belief and Attitude 
Survey (NABAS), 2008. 



Perceptions of the Effectiveness of 
Treatment 

Despite respondents' limited awareness of 
effective science-based treatments for addiction, 
the majority of respondents to the NABAS 
reported believing that if a person admits to 
having a problem and wants to get better, 
addiction treatment is somewhat or very 
effective: approximately eight in 10 indicated 
that treatment for addiction involving alcohol 
(82.5 percent) or prescription drugs (79.9 
percent) is effective, and about three quarters 
indicated that treatment for addiction involving 
illicit drugs (73.6 percent) and tobacco (73.1 
percent) is effective. 431 (Figure 5.D) 



Figure 5.D 

Percent of Public Agreeing that 
Addiction Treatment Is Somewhat/Very Effective, 
by Substance Involved 



82.5 


79.9 


73.6 




73.1 

































Alcohol 



Prescription Drugs Illicit Drugs 



Tobacco 



Source: CASA Columbia National Addiction Belief and Attitude 
Survey (NABAS), 2008. 



It is important to note, however, that a significant 
proportion of the public defines treatment in a way 
that is not consistent with the science of best 
practices in treatment. 



-116- 



These data are consistent with those of other 
recent surveys. One found that the majority of 
Americans believe that treatment programs can 
help people with addiction involving alcohol (8 1 
percent), prescription drugs (79 percent), 
marijuana (78 percent) or other illicit drugs (69 
percent). 432 Another found that 88 percent of 
Americans believe that addiction treatment is 
extremely or very important in helping people 
get better and 77 percent believe that long-term 
recovery is unlikely to be successful without 
treatment and continued support. 433 



-118- 



Chapter VI 

Tailored Treatment for Special Populations 



Diseases manifest differently in different 
individuals and, as with other health conditions, 
a one-size-fits-all approach to addiction 
treatment typically is a recipe for failure. 1 For 
addiction treatment to be effective, it must be 
tailored to the individual patient, including the 
particular stage and severity of the disease, 
overall health status including any co-occurring 
conditions, past treatments and any other life 
circumstances that might affect patient 
outcomes. 2 Treatment approaches also must be 
appropriate to the patient's age, gender, 
race/ethnicity and cultural background. 3 

Although research on the effectiveness of 
various treatment approaches for special 
populations is very limited, particular subgroups 
for whom there is some documented evidence of 
the benefits of specialized treatment include: 
those with co-occurring health conditions, 
adolescents, women, older adults, racial and 
ethnic minorities, individuals of minority sexual 
orientation, veterans and those in active duty 
military, and individuals involved in the justice 
system. 

Co-occurring Medical Disorders 

Because addiction causes, contributes to and co- 
occurs with multiple other diseases, including 70 
other conditions requiring medical care such as 
heart disease and cancer, ' 4 physicians and other 
medical professionals must address these co- 
occurring health conditions in the course of 
caring for their patients and assure that 
medication interactions and the use of 



The following discussion is a brief overview of 
tailored treatment approaches for special populations 
and is not an exhaustive or definitive account of all 
possible treatments of this nature. More research is 
needed to identity the best treatment approaches for 
the special populations discussed in this chapter as 
well as for others not included here. 
f See Chapter III. 



-119- 



potentially addictive medications are considered 
and monitored. 5 

For example, patients treated with opioids for 
pain may be at risk for developing addiction, 
particularly if they do not take them as 
prescribed. 6 Likewise, the frequent use of 
addictive substances such as cocaine can result 
in a range of gastrointestinal and cardiac 
complications that can affect various organs in 
the body; medications used in detoxification and 
addiction treatment may further complicate these 
medical conditions. 7 

The efficacy of particular addiction treatment 
approaches has not been examined 
systematically in patient populations with co- 
occurring medical conditions. However, 
medical and other health professionals should 
plan carefully the treatment protocols for 
patients with co-occurring addiction and other 
medical conditions, be prepared to monitor and 
address emergent reactions that may arise in the 
course of treating these patients and consult with 
specialists in other medical sub-specialties when 
necessary. 8 

Co-occurring Mental Health 
Disorders* 

In the late 1 970s, treatment professionals began 
to recognize the effect that co-occurring mental 
health disorders had on patients' success in 
addiction treatment. Around the same time, 
treatment professionals and programs began to 
document the large number of addiction and 
mental health treatment seekers suffering from 
both sets of problems/ 9 

Traditionally, patients with co-occurring 
addiction and mental health disorders were sent 
to one treatment setting or another to address 
their problems sequentially. 10 Patients have 



The treatment programs discussed in this section 
represent the main evidence-based treatment 
modalities for individuals with co-occurring 
addiction and mental health disorders. It is not a 
comprehensive list of available programs. 
* See Chapter III for data on the prevalence of co- 
occurring addiction and mental health disorders. 



been advised either to "solve" their addiction 
problems before entering mental health 
treatment or stabilize their mental health 
problems before entering addiction treatment. 11 
This approach has not been effective since each 
condition tends to exacerbate the other. 12 

Current standards call for treatment programs 
serving patients with addiction and mental 
health disorders to provide integrated care that 
treats both conditions simultaneously. 13 
Treatment providers may coordinate addiction 
and mental health treatment services by 
combining therapies or by managing the care 
while patients receive both types of treatments 
concurrently. 14 



Integrating addiction treatment and mental 
health care for patients with co-occurring 
disorders increases retention and yields positive 
outcomes, including higher abstinence rates and 
reduced hospitalization and arrest rates. 16 
Integrated treatment also helps providers prevent 
adverse drug interactions among their patients 
and ensure that proper medication dosage is used 
to treat both conditions. 17 



Essential Program Components and 
Principles for Treating Patients with 
Co-occurring Disorders 15 

• Coordinated treatment and recovery plan; 

• Access to addiction and regular medical and 
mental health services within the same 
facility or through collaborating programs; 

• Specialists to provide addiction treatment, 
psychiatric services and other health care 
services as needed; 

• Patient information about the nature of the 
disorders, the importance of lifestyle 
changes and adherence to treatment 
regimens and strategies for relapse 
prevention; 

• Comprehensive support services to address 
issues such as housing and unemployment; 

• Access to mutual support programming; and 

• Reintegration of patients with their families 
and communities. 



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Tobacco Cessation 

Smoking rates are high among individuals with 
mental health disorders, due to common 
neurobiological and psychosocial risk factors, 
the tendency to smoke as a means of self- 
medication and a reduced ability to manage the 
difficult process of cessation. 18 

Practice guidelines for smoking cessation 
underscore the importance of providing smoking 
cessation services to patients with co-occurring 
mental health disorders, utilizing motivational 
and cognitive-behavioral approaches and 
combining psychosocial therapies with 
pharmaceutical interventions-practices that 
mirror those that are recommended for the 
general population. 19 However, in implementing 
these approaches, care must be taken to ensure 
that interventions are tailored to the clinical 
needs of the patient and that such interventions 
do not contraindicate other treatments the patient 
might be receiving for his or her mental illness. 20 

Bupropion has been approved by the FDA as 
both a smoking cessation medication and an 
antidepressant, making it uniquely suited to treat 
individuals with co-occurring mood disorders 
and addiction involving nicotine. 21 Preliminary 
findings indicate that use of bupropion, in 
conjunction with nicotine replacement therapy 
(NRT), can be particularly helpful in treating 
patients with co-occurring mental health 
disorders. 22 However, research on smoking 
cessation interventions in populations with co- 
occurring mental health disorders is very 
limited, in part because patients with such 
disorders historically have been excluded from 
many smoking cessation studies. 23 

Monitoring a patient's smoking and cessation 
activities is extremely important for those with 
mental illnesses since tobacco use can affect the 
treatment of mental health disorders. 24 For 
example, because smoking may influence the 
metabolism of certain commonly prescribed 
psychiatric medications, dosages of these 
medications may need to be adjusted when a 



Smokers typically need twice the dosage of these 
medications than nonsmokers. 



patient is cutting back or quitting their ingestion 
of tobacco products. 25 

Treatment for Addiction Involving Alcohol 
and Other Drugs 

Psychosocial interventions have proven effective 
for patients with co-occurring mental health 
disorders and addiction. 26 Patients with co- 
occurring schizophrenia and addiction appear to 
respond positively to psychosocial approaches 
that include cognitive behavioral therapy (CBT), 
motivational interviewing (MI) and family 
therapy components. 27 Patients with co- 
occurring addiction and mood disorders respond 
well to behavioral skills training.* 28 Integrated 
group therapy (IGT), a CBT-based intervention 
for co-occurring addiction and bipolar disorders, 
was found to be significantly more beneficial 
than a standard group therapy program: in one 
study, IGT patients used alcohol and other drugs 
half as often as other patients did during the 
intervention and three months after treatment. 29 

There also is evidence of the efficacy of 
pharmaceutical interventions for patients with 
co-occurring disorders. 30 Antidepressants, 
including selective serotonin reuptake inhibitors 
(SSRIs), are an effective pharmaceutical 
treatment for many individuals with co- 
occurring mood disorders and addiction 
involving alcohol 31 and may be effective for 
patients with co-occurring mental health 
disorders and addiction involving opioids or 
sedatives as well. Stimulating antidepressants, 
such as desipramine or bupropion, may be more 
useful for treating patients with co-occurring 
depression and addiction involving cocaine. 32 
Preliminary research also suggests that certain 
anticonvulsant medications may be effective in 
treating patients with co-occurring mood or 
anxiety disorders and addiction involving 
alcohol. 33 



1 The behavioral skills training model utilized a 
psycho-educational approach to teach patients self- 
management skills and provide opportunities for 
practice. 



-121- 



While evidence regarding effective treatments 
for addiction and co-occurring trauma disorders 
is limited, psychotherapeutic approaches, 
typically involving CBT and a 
psychoeducational component, appear to be 
quite effective. 34 



Adolescents 

Treatment approaches for adolescents must be 
tailored to the profound neurochemical, 
physical, cognitive, emotional and social 
changes that take place during adolescent 
development and to the heightened influence of 
family and peers relative to adult patients. 41 
Because early initiation of substance use is 
related so strongly to the risk of addiction, 42 
interventions for young people demonstrating 
early signs of risky substance use and treatment 
for addiction is imperative. 43 Treatment 
approaches with a strong evidence base in adult 
populations are not necessarily applicable to the 
treatment needs of adolescents with addiction. 44 

The clinical presentation of addiction often 
differs in adolescents compared to adults: 
adolescents typically do not demonstrate the 
same extent of physical dependence (i.e., 
tolerance and withdrawal) symptoms; 
progression from use to addiction often is more 
rapid; and co-occurrence with mental health 
disorders is more common. 45 

Treatment programs for adolescents should be 
developmentally appropriate and family 
oriented. 46 Special care should be taken when 
providing group-based therapy to adolescents 
who may be more vulnerable than adults to 
potential negative peer influences; this is 
especially true when the group contains 
members with significant behavioral problems. 47 
A significant proportion of adolescents with 
addiction have histories of trauma or adverse life 
experiences as well as co-occurring disorders 
that must be addressed in treatment. 48 

Tobacco Cessation 

A range of effective options exists for teen 
smoking cessation, including NRT, 49 educational 
programs that offer life-skills training and 
counseling interventions. 50 A meta-analysis of 
48 smoking cessation program studies from 
1970 to 2003 for adolescents ages 12-19 found 
that the odds of quitting for smokers in these 
programs increased by 46 percent. Higher quit 
rates were found in programs that included 



Integrated Treatment for 
Co-occurring Disorders 

Originally developed to treat patients with a 
serious mental illness, Assertive Community 
Treatment (ACT) was modified in the late 1990s 
to serve patients with co-occurring addiction and 
mental health disorders. 35 The ACT model is an 
effective way of delivering integrated dual 
disorders treatment (IDDT), also known as 
integrated treatment for co-occurring disorders. 
This integrated approach to treatment for people 
with mental illness and addiction should include 
the following components: staged interventions, 
assertive outreach, motivational interventions, 
counseling, social support interventions, a long- 
term perspective to treatment, comprehensiveness 
and cultural sensitivity and competence. 36 The 
approach relies on a multidisciplinary team of 
providers and intensive outreach activities- 
including providing services to patients in their 
homes and communities— to keep participants 
actively engaged in a high-intensity outpatient 
treatment model. 37 The services provided 
combine treatment approaches such as 
motivational interviewing (MI) or cognitive 
behavior therapy (CBT) with support services 
such as psycho-educational instruction about 
addiction, 12-step mutual support programming 
and life skills training. 38 Patients are monitored 
closely and have access to crisis intervention 
services 24 hours a day. 39 

Participation in this type of program is associated 
with reduced alcohol and other drug use (based on 
clinicians' reports), reduced hospital utilization, 
lower post-treatment relapse rates and improved 
quality of life. 40 



-122- 



motivational-enhancement therapy (MET), CBT 
and social influence approaches in which 
adolescents address the influences that promote 
or maintain smoking behavior. 51 

Treatment for Addiction Involving Alcohol 
and Other Drugs 

Psychosocial therapies such as CBT 52 and 
family-based therapies are effective treatments 
for adolescents with addiction. 53 Interventions 
that integrate a family component into 
psychosocial interventions are particularly 
effective for adolescent patients. 54 Adolescents 
generally seem to fare better in treatment 
programs that include family members in 
counseling sessions or that encourage families to 
take an active role in the treatment process. 55 

Particular types of family-based therapies that 
have proven effective for adolescents include: 

• Multidimensional Family Therapy (MDFT)-- 
an outpatient family-based treatment program 
that addresses adolescent alcohol and other 
drug use in relation to individual-, family-, 
peer- and community-level influences. 56 One 
study found that adolescents who received 
MDFT were likelier than those who received 
other interventions, such as group therapy or 
educational interventions, to complete their 
treatment and to demonstrate reduced alcohol 
and other drug use directly following 
treatment and one year later. 57 

• Functional Family Therapy (FFT)--a 
comprehensive approach to treatment 
implemented in the home or in clinical or 
school settings based on the idea that 
behaviors influence and are influenced by 
multiple systems in the adolescent's life, 
including the family. The three-month 
program consists of engaging and 
motivating adolescents and families; the 
development and implementation of an 
individually tailored, long-term behavior 
change plan; and an attempt to generalize 
positive behavior change to other areas of 
family functioning. Research suggests that 
interventions that include FFT produce 



better treatment outcomes than those 
without an FFT component. 58 

You have an addicted family system. The family 
needs education and therapy, especially with 
adolescents in treatment. 59 

-John Coppola 
Executive Director 
New York Association of Alcoholism and 
Substance Abuse Providers, Inc. (ASAP) 

...It is clear the family plays an important role in 
encouraging and supporting recovery, especially 
in adolescents. 60 

-Jose Szapocznik, PhD 
Professor and Chair, 
Department of Epidemiology and Public Health 
Director, Center for Family Studies 
Director, 
Miami Clinical 
Translational Science Institute 



• Multi-Systemic Therapy (MST)-a family- 
based approach to addressing risk factors 
associated with serious antisocial behavior 
in children and adolescents who use alcohol 
or other drugs. The treatment generally 
takes place in familiar environments (homes, 
schools or other neighborhood settings) 
which contributes to a high retention rate. 61 
In addition to addressing substance use, 
MST also attempts to reduce criminal and 
other forms of problem behavior and 
decrease future involvement with juvenile 
justice and child welfare systems. 62 MST is 
associated with reduced alcohol and other 
drug use during treatment and for at least six 
months following program completion, 63 
and is particularly effective for those 
involved with the juvenile justice system. 64 

A large study of adolescent treatment 
participants in different types of programs 
found that in the year following treatment, the 
percentage of adolescents using marijuana at 
least weekly was cut by approximately half. 



The study included more than 1,100 adolescent 
treatment participants from 23 different programs in 
four cities. 



-123- 



Heavy drinking rates fell from 33.8 percent to 
20.3 percent. The rate of criminal activity also 
declined and indicators of psychosocial 
adjustment, school attendance and academic 
performance improved significantly. 65 

As is true for adults, comprehensive and 
continuing care is critical for adolescents with 
addiction. Assertive continuing care (ACC) is a 
method of enhancing engagement in treatment 
by moving responsibility for service utilization 
from adolescents and their caregivers to 
treatment providers. 66 ACC is characterized by 
at least weekly face-to-face sessions conducted 
in the home or community settings that are 
convenient for the adolescent and increase the 
likelihood of retention and low patient-to- 
provider ratios. Interventions used in ACC 
include an adolescent-oriented community 
reinforcement approach (A-CRA) and intensive 
case management. 67 Research on this approach 
demonstrates that adolescents receiving ACC 
were significantly likelier to be abstinent from 
marijuana following discharge from residential 
treatment than adolescents who did not receive 
ACC;* they also had higher rates of retention in 
aftercare services. 68 

Very few studies have examined the use and 
effectiveness of pharmaceutical interventions for 
the treatment of adolescent patients with 
addiction involving alcohol or other drugs; 69 best 
practice suggests that if they are employed they 
should be used as a supplement to psychosocial 
therapies. 70 

Women 

A considerable body of evidence demonstrates 
the importance of addressing gender differences 
in the treatment process, particularly for women 
with histories of trauma and those who are 
pregnant or parenting. 71 Women often smoke, 
drink and use other drugs for different reasons 
than men and addictive substances affect women 



All participants received referrals to adolescent 
outpatient treatment providers for continuing care in 
their communities following discharge from 
residential treatment. 



differently than men; this may indicate different 
treatment needs. 72 Because the life roles and 
responsibilities of women typically differ from 
men, their support service needs may differ as 
well. 73 Women with addiction have high rates 
of co-occurring mental health disorders, 
including mood, anxiety and eating disorders 
that should be addressed in the treatment 
process, and high rates of trauma histories that 
can influence treatment outcomes. 74 



Gender-specific treatment programs appear to be 
particularly beneficial for women with a history 
of sexual abuse and domestic violence. 76 
Women who were abused as children suffer 
from substance-related problems that are more 
severe than those of their peers, including 
lifetime use of a greater number of substances, 
higher alcohol and other drug severity scores' 
and greater financial and interpersonal 
problems. 77 Women who report exposure to 
physical, sexual or emotional abuse during 
childhood are more prone to relapse than other 
treatment patients, and may be less likely to 
improve during and after treatment. 78 Women 
with trauma histories require a more 
empowering and less confrontational approach; 
being told that they are powerless over their 
addiction-a common tactic in many treatment 
programs that are centered on the 12-step model- 
-can bring back feelings of powerlessness from 
sexual and other abuse. 79 

Pregnant Women 

Pregnant women require special consideration in 
stabilization, acute treatment and disease 
management protocols, particularly with regard 



1 Based on the Modified Michigan Alcohol-Drug 
Screening Test. 



The safety and security of 'all female ' 
[programs] allow women to disclose things that 
are very difficult and that may be impossible 
within a co-ed arrangement. It enhances a 
woman's ability to feel understood and accepted 

75 

without judgment, shame or guilt. 



-124- 



to pharmaceutical interventions. Withdrawal 
from addictive substances during detoxification 
can be highly risky to a fetus; for example, 
sudden withdrawal from certain opioids and 
sedatives can lead to fetal distress or death. 81 As 
a result, detoxification protocols should include 
careful monitoring of the pregnant woman and 
her fetus and medical supervision of the 
detoxification process itself— for example, 
through the use of buprenorphine to treat or 
prevent opioid withdrawal during pregnancy '— 
preferably under the direction of a physician 
with experience in perinatal addiction. 82 
Medically supervised detoxification typically 
takes place during the second trimester because 
of the risk of miscarriage in the first trimester 
and the increased risk of premature delivery or 
fetal death in the third trimester. 83 

Research on the safety and efficacy of 
pharmaceutical therapies for addiction treatment 
among pregnant women is limited. 84 Certain 
medications, such as disulfiram, are not 
considered safe for pregnant women, while 
others, such as methadone, are less risky and 
may be preferable to continued substance use. 85 

Case management is particularly critical for 
pregnant women with addiction. 86 Case 
management services typically assure 
standardized assessments, access to prenatal and 
pediatric care, mental health services, vocational 
and parenting classes, childcare and 

87 

transportation services. 

Pregnant women with co-occurring addiction 
and mental health disorders require additional 
medical monitoring because pregnancy can 
aggravate certain symptoms of mental illness, 
including depression and anxiety. 88 Hormonal 
changes, increased stress and pregnancy-specific 
medications all can contribute to the potential 
exacerbation of mental illness symptoms. 89 



Specific psychosocial treatment approaches that 
work for pregnant women with addiction do not 
appear to differ from those found to be effective in 
the general population of women. 
' Opioid withdrawal during pregnancy can lead to 
fetal death. 



Although federal law requires that pregnant 
women receive priority admission into addiction 
treatment programs, allowing them to bypass 
waiting lists, 90 numerous barriers prevent many 
pregnant women from accessing needed 
treatment. 1 While pregnant women may be 
more motivated than other women to receive 
addiction treatment because of the known risks 
of substance use to pregnant women and their 
babies, they are less likely to stay in treatment 
once admitted, and reductions in substance use 
often are transient and dissipate once their 
children are born. 91 



Older Adults 

Treatment approaches for older adults must take 
into account their increased risk of developing 
addiction involving prescription drugs due to the 
use of medication to treat chronic pain, sleep 
disorders, depression and anxiety-problems that 
are common in this age group— as well as the 
fact that their bodies become even more 
vulnerable to the effects of alcohol and other 
drugs with age. § 94 Co-occurring health 
conditions and medical complications due to 
age-related health problems can interfere with 
addiction treatment and make it harder for older 
adults to follow treatment instructions and 
plans. 95 



1 See Chapter VII. 

§ See Chapter IV for a discussion of the unique risks 
that older adults face with regard to substance use 
and addiction. 



The Center for Substance Abuse Treatment's 
(CSAT) Pregnant and Postpartum Women 
demonstration program provided comprehensive 
clinical, medical and social services, over the 
course of six to 12 months, to pregnant women 
and mothers of children under the age of one. 92 
During the six months following discharge from 
this program, 61 percent of the women had 
achieved and maintained their abstinence from 
alcohol and other drugs. Program participation 
also was associated with increased employment 
rates and decreased rates of arrest, foster care 
involvement and premature deliveries, low birth 
weight and infant death. 93 



-125- 



Psychosocial interventions, particularly 
motivational interviewing (MI) and motivational 
enhancement therapy (MET), are regarded as 
effective approaches for older adults, especially 
those who may resist changing their substance 
use behavior. 96 

Before prescribing a potentially addictive 
medication to an adult patient, a full assessment 
of the patient's use of other addictive substances 
and deliberate counseling with regard to the 
risks of physical dependence and the dangers of 
combining addictive substances is necessary. 
When treating older patients with 
pharmaceutical therapy, long-acting 
benzodiazepines and disulfiram should be 
avoided because of their toxicity. Naltrexone 
has been tolerated well by older adults and there 
is some evidence of its effectiveness in this 
population. 97 

To improve treatment compliance, older patients 
also may require specialized services to assure 
appropriate interventions for dietary deficiencies 
or auditory or visual impairments; to provide 
psychosocial interventions that help patients 
cope with loneliness, loss or depression which 
are more common in this age group; and to help 
bolster supportive social networks. 98 

Racial and Ethnic Minorities 

Treatment providers should take into 
consideration the substance-related health 
disparities-including the likelihood of co- 
occurring disorders— that exist among 
racial/ethnic groups.* 99 Different racial/ethnic 
groups also may vary in their metabolism, 
response to dosages and side effects of 
pharmaceutical interventions for addiction. 100 

While data are not available on specific 
psychosocial therapies that work best for 



e.g., Whites and Hispanics have a higher severity of 
alcohol problems than other racial/ethnic groups (see 
Chapter III); Hispanic and black men have higher 
rates of cirrhosis mortality than white men; and 
Alaska Native and white men report higher rates of 
alcohol-related and non-alcohol-related major 
depressive disorder than Hispanic and black men. 



particular racial/ethnic groups, treatment 
providers should ensure that programs are 
effective for individuals of every racial and 
ethnic background by making them sensitive to 
racial, ethnic and cultural conditions that may 
affect the treatment process. 101 For example, 
providers should make sure that language 
barriers are addressed and require cultural 
competency training for staff. 102 These 
measures improve communication and increase 
trust and understanding, which in turn result in 
greater recognition of patients' needs, increased 
patient engagement in treatment and better 
treatment compliance. 103 

Individuals of Minority Sexual 
Orientation 

Treatment goals for lesbian, gay, bisexual and 
transgender (LGBT) individuals are the same as 
treatment goals for other individuals in terms of 
reducing use or achieving abstinence, but 
treatment should also focus on the unique 
characteristics of LGBT patients. For example, 
higher rates of discrimination against lesbian, 
gay and bisexual adults may be associated with 
higher rates of risky use and addiction in this 
population, compared with heterosexuals. 104 

Treatment providers should screen for other 
health problems and adverse experiences that 
may be more common in the LGBT population 
including co-occurring mental health disorders, 
suicidal thoughts or behaviors, sexually- 
transmitted infections (in particular HIV/AIDS 
and hepatitis A and B) and sexual abuse. 105 Gay 
and bisexual men make up nearly half of those 
living with HIV in the United States; 106 the 
prevalence of mental health disorders is higher 
among lesbian, gay and bisexual adults' than 
among heterosexual adults; 1 107 and a review 
study found that lifetime prevalence estimates of 
sexual abuse range from 15.6 percent to 85.0 
percent for lesbian or bisexual women and from 
11.8 percent to 54.0 percent for gay or bisexual 



Or those who report same-sex sexual partners. 
Or those who report opposite-sex sexual partners. 



-126- 



When assessing available social support for 
LGBT patients, treatment providers should 
recognize that LGBT individuals may 
experience conflict with their family of origin, 
especially around issues of sexual orientation or 
gender identity, and it is important for treatment 
providers to understand the interpersonal 
relationships of their LGBT patients. In 
addition, providers should be particularly careful 
to protect the confidentiality of LGBT patients 
because in many states LGBT individuals lack 
legal protections against discrimination in 
housing, the job market or social services. 109 

Despite the need to tailor addiction treatment to 
the needs of LGBT individuals, national data 
show that only 6.2 percent of treatment facilities 
offered any type of tailored treatment 
specifically for LGBT patients in 2010. 110 A 
2007 national study found that services provided 
by 70.8 percent of LGBT-specialized programs 
did not differ from services provided to patients 
in other programs and only about seven percent 
of facilities offered LGBT-specific services, 
such as special groups for LGBT patients or 
having counselors who were trained specifically 
in LGBT issues. 111 

Research evaluating the impact of treatment 
specific to the needs of LGBT individuals is 
lacking. Among a small sample of individuals 
in addiction treatment, gay and bisexual men in 
LGBT-specialized treatment reported better 
outcomes, such as achieving abstinence and 
completing treatment, than gay and bisexual 
men in traditional treatment. 112 

Veterans and Active Duty Military 

The U.S. Department of Veterans Affairs (VA) 
and the Department of Defense have developed 
practice guidelines for evidence-based addiction 
treatment, and endorsed the U.S. Public Health 
Services' Clinical Practice Guidelines for 
smoking cessation. 113 Among the recommended 
practices for addressing risky use of addictive 
substances and addiction in veterans and active 
duty members of the military are the 
following: 114 



• Active duty members involved in an 
incident in which substance use is 
suspected to be a contributing factor are 
required to be referred to specialty 
addiction care for evaluation. 

• A treatment team shall convene with the 
patient and command in order to review the 
treatment plan and goals. 

• Rehabilitation and referral services for the 
patient require an individualized plan 
designed to identify the continued support 
of the patient with at least monthly 
monitoring during the first year after 
inpatient treatment. 

• For patients who do not stabilize and refuse 
to engage in any type of ongoing care with 
any provider (e.g., medical, psychiatric or 
addiction specialty), consider involving 
supportive family members or significant 
others if the patient agrees. This may 
include a first line supervisor when 
appropriate and the unit commander. 

Of particular importance in the veteran and 
active duty military populations is the need to 
attend to co-occurring mental health conditions, 
particularly post-traumatic stress disorder 
(PTSD), which are common in this 
population. 115 

The VA has outlined certain treatment 
guidelines for veterans and military personnel 
with addiction and co-occurring PTSD, most of 
which mirror the treatment approaches outlined 
in Chapter V for the general population. 
However, the VA notes that treatment for the 
two conditions can be delivered simultaneously, 
that the clinician should use first-stage treatment 
approaches such as motivational interviewing to 
initiate treatment and specifically states that 
tobacco cessation services should be integrated 
into the treatment protocol. 116 The most 
commonly used treatment approach for veteran 
patients with co-occurring addiction and PTSD 
involves cognitive behavioral therapy (CBT). 117 



-127- 



The importance of attending to co-occurring 
conditions in this population is highlighted by a 
study of veterans with co-occurring PTSD and 
addiction who participated in addiction 
treatment* 118 This study found that receiving 
treatment for PTSD during the initial year of 
addiction treatment almost quadrupled 
participants' odds of being in remission from 
addiction^ five years later. 119 

Individuals Involved in the Justice 
System 

In 2006, the National Institute on Drug Abuse 
(NIDA) developed evidence-based principles for 
the effective treatment of individuals in the 
justice system who have addiction. These 
principles include providing comprehensive 
assessments of the extent and severity of 
offenders' substance involvement, addressing 
the presence of co-occurring conditions that 
might call for specialized treatment services, 
assessing treatment progress and adjusting 
interventions accordingly. 120 

For both juveniles and adult offenders with 
addiction, the use of treatment-based alternatives 
to incarceration represents an important step in 
treating the disease. Drug courts, prosecutorial- 
based diversion programs and intensive 
treatment-based probation are some of the 
approaches that have proved effective in the 
justice field. 121 Services also can be provided by 
professionals, using evidence based practices, 
during incarceration and after release. These 
initiatives provide addiction treatment, assure 
collaboration between justice authorities and 
treatment providers and hold the offender legally 
accountable for treatment compliance. 122 



The sample was drawn from male inpatients 
participating in a multisite VA program evaluation of 
addiction treatment. 

' Defined as having (1) abstained from all 13 
substances investigated, (2) had no problems related 
to alcohol or other drugs and (3) consumed 3 oz. 
(88.79 ml) or less of alcohol per day on maximum 
drinking days in the past month. Freedom from 
problems related to substance use was reflected by a 
response of "never" to each of 15 problems in the 
areas of health, work, legal situation and finances. 



Juvenile Offenders 

Comprehensive treatment and management of 
addiction in the juvenile justice population result 
in decreased substance use, crime (recidivism), 
homelessness and high-risk sexual behavior; 
improved school performance, productivity, 
employment and future earning power; and 
better health and psychological adjustment. 123 

For adolescents in the juvenile justice system, 
screening and comprehensive assessments are 
critical for identifying an adolescent's needs and 
for connecting the juvenile with effective 
interventions and treatments. Comprehensive 
assessments can take place at various points, 
including at the first interview after referral to 
juvenile court (often conducted by an intake 
officer) where results may be used to refer the 
adolescent to more appropriate community 
health services rather than incarceration. 
Assessments also may be conducted upon 
admission to a pre-trial detention center to await 
adjudication or upon admission to a post- 
adjudication community program or correctional 
facility. 124 

Addiction treatment for juvenile offenders 
should reflect the standards of evidence-based 
care for adolescents in the general population, 
with a special focus on family-based treatment 
models. Effective treatment approaches include 
multidimensional family therapy (MDFT), 
functional family therapy (FFT) and multi- 
systemic therapy (MST). 125 

Adult Corrections 

Treatment tailored to criminal justice 
populations should ensure that treatment plans 
correspond with correctional supervision 
requirements as well as the medical and social 
support services that the patient may need. 126 

Cognitive behavioral therapy (CBT), 
motivational enhancement therapy (MET) and 
contingency management (CM) have been 
shown to be effective treatment approaches for 
inmates, 127 particularly in that they help train 
patients to recognize errors in judgment that lead 
to substance use and to criminal behavior, 128 and 



-128- 



help to increase treatment engagement and 
retention. 129 As is true in the general population, 
evidence-based pharmaceutical interventions 
should be provided to patients in the criminal 
justice population along with psychosocial 
therapies. 130 

Individuals with addiction facing release and 
reentry should be assured appropriate post- 
release community-based treatment, disease 
management and support services. 131 



-130- 



Chapter VII 

The Addiction Treatment Gap 



In spite of the facts that 15.9 percent of the U.S. 
population ages 12 and older report meeting 
clinical criteria for addiction and that evidence- 
based interventions and treatments are widely 
available, research clearly indicates that only a 
small fraction of those in need of addiction 
treatment receives it and, of those who do, few 
receive evidence-based care. Determining the 
exact size and shape of the addiction treatment 
gap in this country is impossible due to 
significant data limitations;* however, 89.1 
percent of those who meet criteria for addiction 
involving alcohol and drugs other than nicotine 
report receiving no treatment f at all.* 1 



There are no national data on the total number of 
people who receive treatment for the disease. Rather, 
existing data on addiction treatment exclude 
addiction involving nicotine, and data on the types of 
services offered and venues in which they are 
provided are available only for providers that receive 
public funds. Because some addiction treatment 
providers accept both public and private funding, the 
available data on providers serving publicly-funded 
patients also include an unidentifiable number of 
patients who receive private funding. 
f For the purposes of the present analyses, treatment 
includes: (1) services received at non-intensive or 
intensive non-residential settings (including alcohol 
or other drug rehabilitation facilities, mental health 
centers or facilities or doctors' or mental health 
professionals' private offices); and (2) short- or long- 
term residential settings (including alcohol or other 
drug rehabilitation facilities, hospital or mental health 
centers or facilities) in the past 12 months. 
Detoxification, services received in an emergency 
department or in prison or jail settings, mutual 
support programs, peer counseling and other support 
services (including religious-based counseling) are 
excluded from these analyses. 
* While 31.7 percent of the U.S. population ages 12 
and older engage in risky use but do not meet criteria 
for addiction, there has been no attempt to document 
nationally the proportion of this population that 
receives evidence-based screening and brief 
interventions, leaving the size of the intervention gap 
for risky users unknown. Therefore, this chapter 
focuses exclusively on the treatment gap for 
individuals with addiction. 



-131- 



Of those whose addiction involves nicotine, the 
only data available are for persons ages 1 8 and 
older who have tried to quit smoking; less than 
one-third (31.7 percent) of these individuals 
receive smoking cessation services. 1 2 

A key factor contributing to the treatment gap is 
the way treatment costs are covered. In contrast 
to the role of private insurance in medical care 
spending-where it covers 55.6 percent of 
costs, private insurers cover only 20.8 percent of 
the costs of addiction treatment, and the private 
share has been decreasing. Instead, public 
spending accounts for 79.2 percent of the costs 
of addiction treatment in the United States. 3 
This skewing of services to populations 
dependent on public resources is in part a result 
of our failure to prevent and treat this disease. 
Public spending also has concentrated available 
resources for treatment in non-residential 
services operated outside of the mainstream 
health care system. In both public and private 
plans, insurance coverage for addiction care has 
been limited in the range of covered services. 4 

National data indicate that people in need of 
help for addiction largely choose to turn to a 
health professional; however, only 5.7 percent of 
referrals to addiction treatment come from 
health professionals. The largest share of 
referrals— 44.3 percent— comes from the criminal 
justice system, 5 demonstrating our nation's 
attention to the social consequences of addiction 
rather than to prevention and treatment of the 
disease. Even those who are referred to 
treatment may face long waits for admission and 
the longer the wait the less likely patients are to 
enter or complete treatment. 6 

Only 42. 1 percent of those receiving treatment 
for addiction involving alcohol or drugs other 
than nicotine complete their course of care. 7 
The highest treatment completion rates are from 
venues to which there are the least referrals- 
residential treatment; the lowest treatment 



Among current smokers who tried to quit in the past 
year and former smokers who successfully quit in the 
past two years. 

f In the form of counseling or smoking cessation 
medications. 



completion rates are from venues to which there 
are the most referrals-non-residential 
treatment. 8 

A range of factors contribute to these spending, 
referral and service delivery patterns that 
account for the treatment gap, including a 
misunderstanding of the disease of addiction, a 
lack of appropriate disease staging and treatment 
services, 1 negative public attitudes and behavior 
toward those with the disease, privacy concerns, 
cost, lack of information on how to get help, 
limited availability of services including a lack 
of trained addiction physician specialists, 
insufficient social support, conflicting time 
commitments, negative perceptions of the 
treatment process and legal barriers. Certain 
populations with addiction, including those with 
co-occurring health conditions, pregnant and 
parenting women, adolescents, older adults, the 
homeless, veterans and those in active duty 
military, individuals living in rural areas and 
Native Americans, face additional barriers. 

This chapter examines the disconnect between 
those in need of treatment and those who receive 
it. The fact that those who do receive some form 
of treatment rarely receive quality, evidence- 
based care is discussed in Chapter X. 



1 See Chapter X. 

-132- 



Most People in Need of Treatment 
Do Not Receive It 

In 2010, 15.9 percent of the U.S. population 
ages 12 and older-40.3 million people-met 
diagnostic criteria for addiction. Although 
some treatment providers are beginning to 
address the disease of addiction 
comprehensively, including all involved 
substances, no single national data source exists 
to compare the proportion of the population in 
need of addiction treatment' involving any 
addictive substance (including nicotine) to the 
proportion that receives such treatment. CASA 
Columbia's analysis of the treatment gap in the 
following discussion, therefore, is based on 
available data and limited to the 9.1 percent 
(23.2 million) whose addiction involves alcohol 
or other drugs excluding nicotine. i 9 

CASA Columbia's analysis indicates that only 
one in 10 (10.9 percent, 2.5 million) of those in 
need of addiction treatment (excluding nicotine) 
receive it, leaving a treatment gap of 20.7 
million individuals. The proportion of 
individuals in need of addiction treatment who 
actually receive it has changed little since 2002, 
when 9.8 percent of those in need received it. 10 
This is in stark contrast to the much smaller 



treatment gaps that exist for other major health 
conditions including hypertension, diabetes and 
major depression. 5 11 
(Figure 7 A) 



Figure 7. A 

Individuals with Select Medical Conditions 
Who Receive Treatment 




Hypertension 1 



Diabetes 2 



Major 
Depression 3 



Addiction 3 
(excluding 
Nicotine*) 



1 Ages 18 and older; Ostchega, Y., Yoon, S.S., Hughes, J. & Louis, T. 
(2008). 

2 All ages; Centers for Disease Control and Prevention. (201 1). 

3 Ages 1 2 and older; CASA Columbia analysis of The National Survey 
on Drug Use and Health (NSDUH), 201 

* Due to data limitations. 



Those meeting criteria for addiction include 
individuals who met the Nicotine Dependence 
Syndrome Scale (NDSS) criteria for past month 
nicotine dependence, or the DSM-IV clinical 
diagnostic criteria for past year alcohol and/or other 
drug abuse or dependence. This estimate excludes 
the institutionalized population, for which rates of 
addiction are higher. 

' Those in need of treatment are defined not only as 
those who met DSM-IV diagnostic criteria for past 
year alcohol and/or other drug abuse or dependence, 
but also those who have received formal treatment 
for addiction involving alcohol and/or other drugs in 
the past year. Due to data limitations, individuals in 
need of treatment for addiction involving nicotine are 
not included in this analysis. 
* Another nine percent (22.9 million) of the 
population has addiction involving nicotine; 2.7 
percent of the population (7.0 million) has addiction 
involving multiple substances, including alcohol, 
illicit drugs, controlled prescription drugs and/or 
nicotine. 



s For this comparison, CASA Columbia examined the 
referenced national survey data to determine the 
proportion of the population with each disease— those 
with diagnosed or undiagnosed hypertension (59.3 
million); those with diagnosed or undiagnosed 
diabetes (25.8 million); those who met clinical 
criteria for a major depressive episode in the past 
year and/or received professional treatment (saw a 
doctor, received medication, some combination 
thereof) (22.4 million); and those who met clinical 
criteria for addiction involving alcohol or other drugs 
excluding nicotine in the past year and/or received 
professional treatment for alcohol and/or other drugs 
in the past year (23.2 million)— who received 
treatment. 



-133- 



Other national data indicate that, in 2010 among 
smokers age 18 and older, 68.8 percent tried to 
stop smoking* but only 31.7 percent of those 
who tried to stop received some type of smoking 
cessation service (psychosocial or 
pharmaceutical treatment).^ 12 

Variations in the Treatment Gap by 
Primary Substance Involved 

In 2010, 7.4 percent of the population needed 
treatment for addiction involving alcohol* and 
3.1 percent needed treatment for addiction 
involving another drug (excluding nicotine); 5 1.3 
percent of the total population needed treatment 
for addiction involving multiple substances, 
excluding nicotine." While considerably more 
people needed treatment for addiction involving 
alcohol (18.7 million) compared to those 
needing treatment for addiction involving an 
illicit or controlled prescription drug (7.9 
million) or multiple substances (3.4 million), 11 13 
they were less likely to receive it: 

• 8.8 percent (1.7 million) of those in need of 
treatment for addiction involving alcohol 
received it, leaving a treatment gap of 17.1 
million people; 



The source of these data does not present the 
proportion of the sample that smoked, just the 
proportion of smokers that tried to quit. 
' Among current smokers who tried to quit in the past 
year and former smokers who successfully quit in the 
past two years. Trend data are not available for these 
measures. 

* 18.1 percent of these individuals also needed 
treatment for addiction involving other drugs. 
§ 43.1 percent of these individuals also needed 
treatment for addiction involving other drugs, 
excluding nicotine. 

The 7.4 percent of those needing treatment for 
addiction involving alcohol and the 3.1 percent 
needing treatment for addiction involving other drugs 
overlap with the category needing treatment for 
multiple substances. Looking at mutually exclusive 
categories, 6.0 percent needed treatment for addiction 
involving alcohol only and 1.8 percent needed 
treatment for addiction involving other drugs 
(excluding nicotine) only. 
1 f Individuals in need of treatment for addiction 
involving multiple substances also are included in the 
other two categories. 



19.9 percent (1.6 million) of those in need of 
treatment for addiction involving another 
drug (excluding nicotine) received it, 
leaving a treatment gap of 6.3 million 
people; and 

28.5 percent (1.0 million) of those in need of 
treatment for addiction involving multiple 
substances (excluding nicotine) received it, 
leaving a treatment gap of 2.4 million 
people. 14 (Figure 7.B) 



Figure 7.B 

The Treatment Gap: 
Need for Addiction Treatment 
and Receipt of Needed Services 
(Excluding Nicotine), 2010 



18.7M 



I Need for Treatment 
i Receipt of Treatment 



7.9M 



1.6M 



3.4M 



1.0M 



Alcohol 



Other Drugs 



Multiple Substances 



Note: Individuals who need and/or receive treatment for addiction 
involving multiple substances also are included in the other two 
categories. 

Source: CASA Columbia analysis of The National Survey on Drug 
Use and Health (NSDUH), 2010. 



Of the 3 1 .7 percent of those ages 1 8 and older 
who wanted to stop smoking in 2010, 5.9 
percent received cessation counseling** and 30.0 
percent received medications; 55 4.3 percent 
received both. 15 



++ 3. 1 percent used a telephone quitline, 2.6 percent 
received one-on-one counseling and 2.4 percent were 
involved in a stop smoking clinic, class or support 
group. 

§§ 14.6 percent used the nicotine patch, 1 1.2 percent 
used the medication varenicline, 8.9 percent used the 
nicotine gum or lozenge, 3.2 percent used the 
medication bupropion and 1 .0 percent used the 
nicotine spray/ inhaler. 



-134- 



Variations in the Treatment Gap by Key 
Patient Characteristics 

The addiction treatment gap is substantial across 
all demographic groups, with the greatest need 
among adolescents, young adults and 
Hispanics. 16 

Gender. In 20 1 0, twice as many males as 
females were in need of addiction treatment 
(12.2 percent vs. 6.2 percent). 17 That year: 

• 10.5 percent of males in need of treatment 
received it, leaving a treatment gap of 13.5 
million; and 

• 11.7 percent of females in need of treatment 
received it, leaving a treatment gap of 7.2 
million. 18 

Although more males than females had 
addiction involving nicotine in 2010 (9.9 percent 
vs. 8.2 percent), 19 more female than male 
smokers were interested in quitting (70.7 percent 
vs. 67.3 percent) and treatment was more 
prevalent among females than among males 
(35.1 percent vs. 28.8 percent). 20 

Age. In 2010, young people ages 18 to 25 were 
the most likely of all age groups to need 
addiction treatment: 

• 7.5 percent of teens ages 12 to 17 and 20.5 
percent of young adults ages 1 8 to 25 were 
in need of treatment (15.1 percent of all 12 
to 25 year olds) but only 1 . 1 percent of all 
12 to 25 year olds received it,* leaving a 
treatment gap of 8.2 million; and 

• 7.4 percent of adults ages 26 and older were 
in need of treatment but only 1.0 percent 
received it, leaving a treatment gap of 12.5 
million. 21 



Although more 18- to 25-year olds than adults 
ages 26 and older had addiction involving 
nicotine (10.4 percent vs. 9.7 percent) in 20 10, 22 
those ages 26 and older^ were more likely to be 
interested in quitting, and smoking cessation 
treatment was higher among those ages 25 and 
older (29.4 percent of 25- to 44-year olds; 42.3 
percent of 45-to 64-year olds; and 35.9 percent 
of those ages 65 and older) than among 18- to 
24-year olds (15.8 percent). 23 

Race/Ethnicity. Similar to racial/ethnic 
disparities that have been found for other health 
conditions, 24 Hispanics were slightly likelier 
than white or black people to need addiction 
treatment (10.1 percent vs. 9.3 percent and 8.8 
percent, respectively) but less likely to receive it 
in2010: 25 

• 7.0 percent of Hispanics in need of treatment 
received it, leaving a treatment gap of 3.5 
million; 

• 11.7 percent of whites in need of treatment 
received it, leaving a treatment gap of 13.9 
million; and 

• 11.9 percent of blacks in need of treatment 
received it, leaving a treatment gap of 2.4 
million/ 26 

Whites were likelier than blacks or Hispanics to 
have addiction involving nicotine (10.9 percent 
vs. 6.9 percent and 4.2 percent, respectively), 27 
but adult black smokers were likelier than adult 
white and Hispanic smokers to be interested in 
quitting in 2010 (75.6 percent vs. 69.1 percent 
and 61.0 percent, respectively). White smokers, 
however, were likelier to use smoking cessation 
treatments than black or Hispanic smokers (36.1 
percent vs. 21.6 percent and 15.9 percent, 
respectively). 28 Other research supports the 



1 Interest in quitting was higher among adults ages 25 
to 44 (72.5 percent) and ages 45 to 64 (69.0 percent) 
relative to those ages 18 to 24 (66.7 percent); older 
adults ages 65 and older were the least interested in 
quitting (53.8 percent). 

* A recent study found that black and Hispanic 
adolescents are significantly less likely to receive 
addiction treatment relative to white adolescents. 



The sample sizes for those who received needed 
treatment is too small to report statistically reliable 
data for 12- to 17-year olds and 18- to 25-year olds 
separately. 

-135- 



finding that black and Hispanic smokers are less 
likely than white smokers to use smoking 
cessation interventions such as nicotine 
replacement therapy (NRT) and other 
pharmaceutical therapies. 29 

Special Populations. The need for addiction 
treatment is disproportionately higher for 
individuals with co-occurring mental health 
disorders, for individuals involved in the justice 
system and for members of the military, 
including veterans, returning from active combat 
in Iraq and Afghanistan: 

• In 2010, one in five (20.7 percent) non- 
institutionalized individuals ages 1 8 and 
older* with a diagnosed mental health 
disorder' were in need of addiction 
treatment (relative to 6.3 percent of those 
without a diagnosed mental health disorder); 
14.2 percent of those in need of addiction 
treatment received it, leaving a treatment 
gap of 8.5 million adults with co-occurring 
addiction and mental health disorders.* 30 In 
2010, only 37.6 percent of facilities 
nationwide that provided addiction treatment 
services offered services specific to patients 
with co-occurring addiction and mental 
health disorders. 31 

• In 20 1 0, adults with a mental illness were 
more than 1.5 times as likely as those 
without a mental illness to have smoked 
cigarettes in the past year (41.3 percent vs. 



Comparable data on those with mental health 
disorders are not available for those ages 12-17. 
1 And/or a reported major depressive episode. 
* Research indicates that young people with co- 
occurring conditions are more easily identified as 
needing treatment than those with addiction only. 
One study found that unmet treatment need (i.e., the 
treatment gap) was greatest for teens with addiction 
(37 percent) compared to a relatively lower treatment 
gap of 23 percent among those with a psychiatric 
disorder only and 19 percent among those with co- 
occurring disorders. Other research confirms that 
rates of addiction treatment are approximately three 
times higher for adolescent illicit drug users who 
report having received mental health treatment in the 
past 12 months compared to those who have not 
received mental health treatment. 



25. 1 percent). Even though patients with 
mental health disorders are likelier to 
smoke 33 and about as likely to want to quit 
smoking as smokers in the general 
population, 34 research suggests that smoking 
cessation services for these patients are 

§ 35 

rare. 

• In 2010, nearly half (46.8 percent) of 
individuals who were arrested or booked in 
the past year, but not incarcerated at the time 
of the survey, were in need of addiction 
treatment (relative to 8.0 percent of those 
who had not been arrested or booked in the 
past year); 27.9 percent of those in need of 
treatment received it, leaving a treatment 
gap of 2.5 million individuals." 36 In 2010, 
only 26.8 percent of facilities nationwide 
that provided addiction treatment services 11 
offered services specific to patients involved 
in the criminal justice system. 37 Among 
inmates, only 1 1.2 percent receive 
treatment. 

• Individuals involved in the justice system 
also are likelier than the general population 
to smoke 39 but are less likely to receive 
tobacco cessation services. 40 One survey of 
500 correctional facilities**-- including jails, 
prisons and juvenile facilities— found that 80 
percent reported that their facilities had no 
tobacco cessation programs at all. 41 

• In 2005, of veterans from the military 
operations in Iraq and Afghanistan who 
sought health care from the Department of 
Veterans Affairs (VA), 40 percent screened 
positive for risky alcohol use and 22 percent 



§ Based on research documenting health care 
practice; national data on the use of smoking 
cessation treatments in this population are not 
available. 

" Comparable treatment admission data from the 
Treatment Episode Data Set (TEDS), described on 
page 141 and in Appendix A, are not available for 
this population. 

n Excluding facilities such as jails, prisons or other 
organizations that treat incarcerated individuals 
exclusively. 

tJ Accredited by the National Commission 
on Correctional Health Care. 



-136- 



screened positive for a possible addiction 
involving alcohol* However, of those who 
screened positive for risky alcohol use, only 
3 1 percent were advised in the past year to 
drink less or stop drinking; 4 1 percent of 
those with a possible addiction involving 
alcohol were given such advice. 42 Another 
study found that 1 1.8 percent of soldiers 
who returned from Iraq reported risky 
alcohol use but only 0.2 percent were 
referred to treatment and only 21.6 percent 
of those who were referred were seen within 
90 days. 43 And although the Handbook on 
Uniform Mental Health Services requires 
access to opioid maintenance therapy, fewer 
than one in five veterans diagnosed with 
addiction involving opioids receive this kind 
of therapy on an ongoing basis. 44 

Regional Variations in the Treatment Gap 

Current national data on regional differences in 
the proportion of individuals in need of 
addiction treatment are not available. ' However, 
other research indicates that the disparity 
between the number of people who need 
addiction treatment and the number who receive 
it varies substantially among states and regions 
of the country, 45 with southern and southwestern 
states having the largest estimated treatment 
gaps in the nation and the northeast having the 
smallest estimated treatment gap. 46 

Although reasons for these geographical 
differences in the treatment gap are not well 
understood, 47 possible explanations include 
variations among states in funding of treatment 
services, including differences in coverage of the 
costs of these services in state managed care 
systems. 48 One study found that only 21 percent 
of the variation among states in the percent who 
receive treatment was associated with variations 



Based on scores on a version of the AUDIT 
instrument (see Appendix H). Risky drinking was 
defined as an AUDIT-C score of four or higher for 
men and three or higher for women. Addiction was 
defined as an AUDIT-C score of four or higher for 
women and six or higher for men. 
' Public access NSDUH files have not contained 
geographic variables since 1998. 



in the prevalence of addiction; the rest of the 
variation is attributable to these other factors. 49 

Sources of Funding for Addiction 
Treatment 

Spending on addiction treatment totaled an 
estimated $28.0 billion in 2010. Whereas 
private payers (including private insurers and 
self-payers) are responsible for 55.6 percent 
($ 1 .4 trillion) of medical expenditures in the 
U.S., they are responsible for only 20.8 percent 
($5.8 billion) of addiction treatment spending. 50 

Public payers picked up the tab for 79.2 percent 
($22.2 billion) of expenses for addiction 
treatment, with state and local governments 
paying for 44.8 percent ($12.6 billion) and the 
federal government paying for 34.4 percent 
($9.6 billion). 51 (Figures 7.C) 

The concentration of spending for addiction 
treatment in public programs suggests that 
insurance across the board does not adequately 
cover costs of intervention and treatment, with 
costly health and social consequences falling to 
government programs. National data* indicate 
that those with private insurance are three to six 
times less likely than those with public insurance 
to receive specialty addiction treatment. 5 52 



1 From a study examining data from the 2002-2007 
editions of the NSDUH. It is not possible to 
determine from these data why treatment access 
differed based on insurance type since the study 
could not take into account important factors such as 
individual characteristics and circumstances that may 
relate both to type of insurance and likelihood of 
treatment access (e.g., symptom severity, SES). 
§ Defined in the study as treatment received in 
hospital inpatient units, outpatient and residential 
addiction treatment facilities, mental health facilities 
and methadone maintenance facilities. Services 
provided by private physicians (including 
psychiatrists), independent practice mental health 
practitioners, clergy, in prisons/jails and by self-help 
groups are not included in the definition of treatment. 
Those with no insurance are almost twice as likely as 
those with private insurance to receive specialty 
treatment. 



-137- 



Figure 7.C 

Public vs Private Spending 



Medical Care 



Addiction Treatment 



Public 
44.4% 
($1.1 T). 




Private 
55.6% 
($1.4T) 



Public 
79.2% 
($22.2 B) 




Private 
20.8% 
($5.8 B) 



Source: CASA Columbia (2012) analysis of the National Expenditures for Mental Health Services & 
Substance Abuse Treatment 1986-2005 (Table A.1) SAMHSA Spending Estimates Project, 2010; CMS Office 
of the Actuary, National Health Statistics Group with our estimated dollar updates. 



Privately-Funded Treatment 

In 2010, 20.8 percent ($5.8 billion) of addiction 
treatment expenditures came from private 
sources. Private spending includes: 

• 56.6 percent ($3.3 billion) from private 
health insurance; 

• 30.5 percent ($1.8 billion) from self-pay by 
patients; and 

• 12.9 percent ($0.8 billion) from other private 
sources, such as charitable donations and 
charity care/fee waivers. 53 (Figure 7.D) 

Publicly-Funded Treatment 

In 2010 79.2 percent ($22.2 billion) in addiction 
treatment expenditures came from public 
sources. Public spending includes: 

• 45.3 percent ($10.1 billion) from state and 
local government non-Medicaid sources; 

• 26.3 percent ($5.9 billion) from Medicaid; 



Figure 7.D 

Components of Private Addiction 
Treatment Spending (Total $5.8B) 



Other Private. 

Sources 
12.9% ($0.8B) 



Self-Pay 
30.5%($1.8B). 




Private Health 

Insurance 
56.6% ($3.3B) 



Source: CASA Columbia analysis of the National Expenditures for Mental 
Health Services & Substance Abuse Treatment 1986-2005. (2012). 



19.9 percent ($4.4 billion) from other 
federal funds such as block grants to states; 
and 

8.5 percent ($1.9 billion) from Medicare.* 54 
(Figure 7.E) 



Medicaid and Medicare are government programs 
with state and federal contributions. Therefore, the 
estimates reported in the federal, state and local 
categories are exclusive of the estimates of public 
funds spent through Medicare and Medicaid 
programs. 



-138- 



Figure 7.E 

Components of Public Addiction 
Treatment Spending (Total $22.2B) 



Medicare 
8.5% ($1 .9B) 



Other Federal 
19.9% ($4.4B) 



Medicaid 
26.3% ($5.9B) 




Other State & 
Local 
45.3% 
($10.1B) 



Source: CASA Columbia analysis of the National Expenditures 
for Mental Health Services & Substance Abuse Treatment 1986- 
2005. (2012). 



Trends in Spending on Addiction 
Treatment 



Expenditures by Providers and 
Types of Services 

Most expenditures for addiction 
treatment are to non-hospital based 
providers offering outpatient services. 

Providers. Treatment providers 
whose primary role is addiction 
treatment account for 61.7 percent 
($17.3 billion) of the total spending on 
addiction treatment ($28.0 billion). 57 
These expenditures include: 

• 43.4 percent ($12.2 billion) by 
specialty addiction treatment 
centers; 



• 12.8 percent ($3.6 billion) by specialty units 
in general hospitals; and 



Between 1986 and 2010, direct spending on 
addiction treatment increased from $9. 1 billion 
to an estimated $28.0 billion. In constant 
dollars, direct spending on addiction treatment 
nearly doubled during this period, while the 
portion of direct addiction treatment paid by 
private sources fell from 39.8 percent to 20.8 
percent and the portion paid by public sources 
rose from 60.2 percent to 79.2 percent. While 
there also was a shift from private to public 
payment of medical care expenditures during 
this period, the shift was far less pronounced; 
private source payment of medical expenditures 
dropped from 61.2 percent in 1986 to 55.7 
percent in 2005 while public source payment 
rose from 38.8 percent to 44.3 percent. 55 



/ was not able to get help until I got myself into 
the criminal justice system and was then placed 
into treatment as a condition of parole. I tried 
many times to get help for my addiction but due 
to the lack of insurance and money, was 
denied. 56 



• 5.5 percent ($1.5 billion) by specialty 
hospitals. 58 

The remaining expenditures (38.3 percent, $10.7 
billion) are accounted for by facilities and 
individuals that have another primary mission 
but also provide addiction-related services, 
including: 

• 8.8 percent ($2.5 billion) by specialty mental 
health centers; 

• 7.9 percent ($2.2 billion) by health 
professionals other than physicians such as 
counselors, social workers and 
psychologists; 

• 6.8 percent ($1.9 billion) by general hospital 
non-specialty units such as detoxification, 
when a patient with addiction is admitted via 
the emergency room; 



—Respondent to CASA Columbia's 
Survey of Individuals in 
Long-Term Recovery 



Not considered to be addiction treatment. 



-139- 



• 6.7 percent ($1.9 billion) in 
insurance administration; 

• 6.3 percent ($1.8 billion) by 
physicians; 

• 1 .2 percent ($0.4 billion) by 
nursing homes and home health 
care providers; and 

• 0.6 percent ($0.2 billion) in retail 
prescription drugs. 59 (Figure 7.F) 

Services. Total addiction treatment 
spending in 2010 ($28.0 billion) 
included: 

• 92.7 percent ($25.9 billion) for 
services, including: 

> 48.3 percent ($13.5 billion) 
for outpatient services (non- 
hospital, 38.4 percent, $10.8 
billion and hospital, 9.8 
percent, $2.8 billion); 

> 27.9 percent ($7.8 billion) for 

residential (non-hospital 
inpatient) services; and 

> 16.5 percent ($4.6 billion) for 
inpatient hospital services; 

• 6.7 percent ($1.9 billion) in 
insurance administration fees; and 

• 0.6 percent ($0.2 billion) for retail 
prescription drugs. 60 (Figure 7.G) 





Figure 7.F 

Addiction Treatment and 




Related Services Spending* 


Physicians 
6.3% 
($1.8B)_ 

Insurance 

rtUi 1 1 11 llbu dllUl 1 

6.7% 


Nursing 
Homes/Home; 
Health Care 
Providers 
\ 1 .2% 
\f$0.4B) 


Retail 
; Prescription 
Drugs 
0.6% 
($0.2B) 
/ Specialty Mental 
/ Health Centers 
/ 8.8% 


($1.9B) 




^\ ($2.5B) 


General Hospital 
Non-Specialty 
6.8% 






($1.9B) 




/ B Specialty 


Other Health _ 
Professionals 
7.9% 
($2.2B) 




/ Addiction 
/ H Centers 

($12.2B) 


Specialty --' 

Hospitals 
5.5% 






($1.5B) Specialty Units J 
in General 




Hospitals 
12.8% 




($3.6B) 




* The combination of spending by provider type and spending related to other 
categories such as retail prescription drugs and insurance administration is a 
function of the way the national expenditure data are presented by SAMHSA. 
Source: CASA Columbia analysis of the National Expenditures for Mental Health 
Services & Substance Abuse Treatment 1986-2005. (2012). 



Figure 7.G 

Spending by Service (Total $28.0B) 


Insurance 

Arlminktmtinn j. 




Retail 
Prescription 

Drugs 
0.6% ($0.2B) 


6.7% ($1 .9B) s<T 




Inpatient / \ 
Hospital yf \ 
16.5% ($4.6B)^^/ \ 






( 




N. Outpatient 
\^48.3% ($13.5B) 


Residential \ 
27.9% ($7.8B)_^^ 


U 




Source: CASA Columbia analysis of the National Expenditures for Mental 
Health Services & Substance Abuse Treatment 1986-2005. (2012). 



-140- 



Treatment Admissions 

There are no national data on individuals who 
receive addiction treatment in the U.S.; the 
national data that are available represent 
admissions to treatment facilities for addiction 
involving alcohol or other drugs (excluding 
nicotine) for the 79.2 percent of addiction 
treatment funding that comes from public 
sources, although some of these facilities also 
may receive private funding/ 



While some addiction treatment programs may 
address nicotine, they do not report these services in 
their treatment admission data. 
' These analyses are based on data from the 
Treatment Episode Data Set (TEDS), a national 
database of information on the demographic and 
addiction characteristics of admissions to and 
discharges from addiction treatment facilities, 
routinely collected by each state substance abuse 
agency and submitted to the Substance Abuse and 
Mental Health Services Administration (SAMHSA). 
TEDS collects information about the beginning and 
termination of treatment episodes; multiple episodes 
of treatment for the same client are counted 
separately. The 2009 TEDS data are based on 
information on the demographic and substance use 
characteristics of the approximately 1.5 million 
annual admissions to alcohol and other drug 
addiction treatment facilities (excluding 
detoxification), among those ages 12 and older, that 
report to individual state substance abuse agency data 
systems. The TEDS attempts to include all 
admissions to providers receiving public funding; 
however, because each state or jurisdiction decides 
the TEDS eligibility of a provider, there is no 
independent check on the actual sources of funding. 
Although SAMHSA requests submission of TEDS 
data on all admissions to any publicly funded 
treatment facility, reporting in some state agencies is 
structured so that only patients treated with public 
funds are included in the TEDS. The number of 
patients in these facilities whose treatment is not 
publicly funded is unknown. Because the scope of 
facilities included in the TEDS is affected by 
differences in state licensure, certification, 
accreditation and disbursement of public funds, the 
TEDS, while comprising a significant proportion of 
all admissions to addiction treatment, does not 
include all admissions. (See Appendix A for more 
information about TEDS.) It is important to note that 
CAS A Columbia's analyses of TEDS data exclude 
detoxification services in calculating rates of 



P 
E 
R 
C 
E 
N 
T 



In 2009/ there were 1.5 million admissions to 
publicly-funded addiction treatment facilities. 5 
More than half (55.6 percent) of the admissions 
were for addiction involving multiple 
substances. For 38.6 percent of the admissions, 
alcohol was the primary substance of addiction, 
compared with 29.0 percent for illicit drugs 
other than marijuana, 22.4 percent for marijuana 
and 7.9 percent for controlled prescription 
drugs. 61 (Figure 7.H) 



Figure 7.H 

Admissions to Publicly-Funded Addiction 
Treatment by Primary Substance 
and Multiple Substances 











55.6 


38.6 














29.0 


22.4 






i 












n 






7.9 
1 1 



Alcohol 



Marijuana 



Prescription 
Drugs 



Illicit Drugs 
Other Than 
Marijuana 

Note: Admissions for addiction involving multiple substances 
also are included in the other categories. 
Source: CASA Columbia analysis of The Treatment Episode 
Data Set (TEDS), 2009. 



Multiple 
Substances 



Admissions to publicly-funded addiction 
treatment reflect greater attention to addiction 
involving illicit drugs other than marijuana and 
multiple substances relative to the prevalence of 
addiction involving these substances in the 
population. 



62 



admissions to addiction treatment; therefore, data 

reported in this report may differ from those 

published in TEDS reports. 

* The most recent available data. 

§ Included in the TEDS database. 

Of those needing addiction treatment, 80.7 percent 
involve alcohol, 18.9 percent involve marijuana, 10.3 
percent involve controlled prescription drugs and 7.0 
percent involve illicit drugs other than marijuana; 
14.6 percent involve multiple substances. 
(Categories are not mutually exclusive.) 



-141- 



Between 2002 and 2009, treatment 
admissions to publicly-funded addiction 
treatment increased by 7.0 percent (from 
1.4 million to 1.5 million). During that 
time, admissions where prescription 
drugs were the primary substances of 
addiction increased the most— by 92.7 
percent; admissions where marijuana was 
the primary substance of addiction 
increased by 13.1 percent. At the same 
time, admissions where illicit drugs other 
than marijuana were the primary 
substances of addiction declined by 1 1.0 
percent and admissions where alcohol 
was the primary substance of addiction 
declined by 6.5 percent. Between 2002 
and 2009, admissions for addiction 
involving multiple substances declined 
by 1.2 percent. 63 (Figure 7.1) 

Treatment Referrals and 
Venues 

CAS A Columbia's NABAS found that 
46.8 percent of respondents would turn to 
a health professional— such as their 
physician (27.8 percent), a health 
professional other than their primary care 
physician (19.7 percent) or a mental 
health professional (9.2 percent) f ~ if 
someone close to them needed help for 
addiction. 64 (Figure 7. J) 



Figure 7.1 

Trends in Admissions to Publicly-Funded 
Addiction Treatment by Substance, 2002-2009 





70.0 




60.0 


p 


50.0 


E 




R 


40.0 


C 




E 


30.0 


N 


20.0 


T 






10.0 




0.0 




•Multiple 
Substances 

• Alcohol 



Illicit Drugs other 
than Marijuana 

• Marijuana 



2002 2004 2006 2008 2009 



Prescription 
Drugs 



Source: CASA Columbia analysis of The Treatment Episode Data 
Set (TEDS), 2009. 



Figure 7.J 

Where People Would Turn for Information/Help 
with Addiction for Someone Close to Them 










Primary Care Physician 


1 27.8 










Mutual Support Program 


1 ?1 








Other Health Professional 


I 19.7 








P 


"Do Research/Look It Up" 


I 18.8 


E 


Addiction Treatment Center 


I 11.0 


R 

C 


Friend/Family Member 


I I 10.7 


E 
N 
T 


Church/Clergy or Relgious/Spiritual Leader 


ZZI 9-8 


Mental Health Professional 


I 9.2 




Addiction Hotline/Helpline 


I 7.2 




Source: CASA Columbia National Addiction Belief and Attitude 
Survey (NABAS), 2008. 





Not including mental health professionals. 
' Some respondents chose more than one response so 
the 46.8 percent reflects those who chose either one 
of these health professionals. 



-142- 



Another national survey found that 65 percent of 
adults would turn to a health care provider for a 
problem involving alcohol. 65 Despite these 
findings, the smallest proportion of referrals to 
publicly-funded addiction treatment comes from 
health professionals. 66 

Of all the admissions to publicly-funded 
addiction treatment in 2009, 44.3 percent were 
referred by the criminal justice system. One- 
quarter (25.3 percent) of referrals came from 
individuals, including concerned family 
members, friends and the self-referred; f 12.1 
percent were referred by community sources 
such as social welfare organizations, religious 
organizations and mutual support programs;* 
10.6 percent were referred by addiction 
treatment providers 5 * for additional treatment and 



Referrals from the criminal justice system include 
referrals from any police official, judge, prosecutor, 
probation officer or other person affiliated with a 
federal, state or county judicial system. This 
category also includes referrals by a court for 
DWI/DUI, patients referred in lieu of or for deferred 
prosecution, during pretrial release, before or after 
official adjudication, as well as referrals of those on 
pre -parole, pre-release, work or home furlough or 
Treatment Alternatives for Safe Communities 
(TASC). 

' Separate data on each of these categories are not 
available in the TEDS dataset. 
* Community sources of referral also include 
government agencies that provide aid in the areas of 
poverty relief, unemployment, shelter or social 
welfare and referrals from defense attorneys. 
According to the TEDS data, defense attorneys are 
not included in the criminal justice system category; 
prosecutors are included in that category. These 
community referral categories cannot be examined 
separately in the TEDS dataset. 
§ Addiction service providers are those programs, 
clinics or health care providers whose principal 
objective is treating patients with addiction, or where 
a program's services are related to substance use 
prevention or education. TEDS distinguishes 
between transfers within a single, continuous 
treatment episode and the initiation of a new 
treatment episode but, because TEDS relies on state 
administrative systems that appear to differ greatly in 
their ability to distinguish transfers within a 
continuous treatment episode from the initiation of a 
new treatment episode, some transfers may be 
reported by TEDS as new treatment episodes. 



5.7 percent were referred by a health care 
provider. Very few treatment referrals came 
from schools (1.4 percent) 1 ' or from employers 
or Employee Assistance Programs (0.6 
percent). 67 (Figure l.K^) 



Figure 7.K 

Sources of Referral to Publicly-Funded 
Addiction* Treatment 








Criminal Justice System 


1 44.3 








Individuals 


1 25.3 


P 






E 


Community Sources 


1 12.1 


R 
C 
E 


Addiction Treatment Providers 


I 10.6 


Health Care Providers 


■ 5.7 


N 
T 


Schools 


] 1.4 




Employers 


0.6 




* Excluding nicotine. 

Source: CASA Columbia analysis of The Treatment Episode 
Data Set (TEDS), 2009. 





Given that addiction is a medical disease 
requiring the intervention of trained medical 
professionals and the high prevalence of this 
disease in the general population, 55 the fact that 
only 5.7 percent of treatment admissions are 
referred by health professionals highlights the 
extent to which health professionals fail to 
address this disease in their practice. The fact 
that the largest proportion of referrals to 
addiction treatment comes from the criminal 
justice system further underscores how 
extensively we neglect to address addiction until 
the consequences are too dire to ignore. 68 The 



Referrals to treatment programs from health care 
providers include those from physicians (including 
psychiatrists) or other licensed health professionals, 
or from a general hospital, psychiatric hospital, 
mental health program or nursing home. 
(t Including a school principal, counselor, teacher, 
student assistance program (SAP), the school system 
or an educational agency. 
" These data are from the TEDS dataset. 
Comparable data on referral to treatment for nicotine 
addiction (smoking cessation) are not available. The 
data reported here do not include referrals to 
detoxification programs. 
§§ See Chapters II and III. 



-143- 



separation of addiction treatment from 
mainstream health care is demonstrated further 
by the fact that most treatment venues are not 
licensed health care institutions. 69 
(See Chapter IX.) 

Available data on treatment venues to which 
referrals are made distinguish between intensive 
and non-intensive services provided in non- 
residential settings and between short- and 
longer-term services provided in residential 

70 

settings: 

• Non-residential services include individual, 
family, group and/or pharmaceutical 
therapies provided on an ambulatory or 
outpatient basis. Intensive services are those 
that last at least two or more hours per day 
for three or more days per week. 

• Residential services include addiction 
treatment provided in a non-hospital setting, 
and 24-hour per day medical care in a 
hospital facility that includes addiction 
treatment. Short-term services include those 
that last for 30 days or less and longer-terms 
services are those that last for more than 30 
days. 

There are no data available to match the need for 
specific services with referrals to specific 
treatment venues. Although referrals to 
treatment primarily come when addiction has 
advanced to the point of serious social 
consequences (e.g., the criminal justice system) 
and often involve co-occurring health 
conditions, in 2009, the majority of the 1.5 
million treatment admissions were to non- 
intensive and non-residential venues: 71 

• 63.3 percent were for non-intensive, non- 
residential services; 

• 14.6 percent were for intensive, non- 
residential services; 



• 11.9 percent were for short-term residential 
services; and 

• 10.2 percent were for longer-term residential 
services. 72 (Figure 7.L) 



Figure 7.L 

Admissions to Different Types of 
Treatment Service Venues 



p 










E 
R 


63.3 








C 












E 
N 






14.6 


11.9 


10.2 


T 






I I 




Non- 


Intensive Non- 


Short-Term 


Longer-Term 



Intensive/Non- Residential Residential Residential 
Residential Services Services Services 

Services 

Source: CASA Columbia analysis of The Treatment Episode 
Data Set (TEDS), 2009. 



While most admissions regardless of referral 
source are to non-residential venues (77.9 
percent), certain referral sources are even likelier 
than average to result in admissions to non- 
residential services, including: 

• schools (97.8 percent); 

• the criminal justice system (85.5 percent); 

• employers (84.0 percent); and 

• community sources (79.3 percent). 73 

In contrast, while only 22.0 percent of treatment 
admissions overall are referred to residential 
treatment venues, 47.8 percent of those referred 
by addiction treatment providers are to 
residential treatment venues. 74 (Table 7.1) 



-144- 



Table 7.1 

Admissions to Different Types of Treatment Service Venues 
by Source of Referral, 2009 (Percent) 



Source oi 


Non- 


Intensive 


Snort- 1 erm 


Longer- 


Relerral 


Intensive 


Non- 


T» "J 4.' 1 

Residential 


Term 




XT 

Non- 


Residential 




Residential 




Residential 








Total 


63.3 


14.6 


11.9 


10.2 


Criminal 


69.7 


15.8 


6.3 


8.1 


Justice 










System 










Individual 


61.0 


13.7 


14.2 


11.1 


Referrals 










Community 


62.3 


17.0 


11.2 


9.6 


Sources 










Addiction 


41.3 


10.9 


29.0 


18.8 


Treatment 










Providers 










Health Care 


60.2 


12.7 


17.5 


9.6 


Providers 










Schools 


88.2 


9.6 


1.3 


0.9 


Employers 


67.3 


16.7 


13.6 


2.5 



Treatment Completion 

In 2008,* less than half (42.1 percent) of 
discharges from addiction treatment services 1 
were of admissions in which treatment was 
completed. * 75 The highest completion rates 
were from venues to which there were the least 
referrals: 

• 14.8 percent of admissions were to short- 
term residential services which had the 
highest completion rate of 54.8 percent; 

• 11.4 percent of admissions were to longer- 
term residential treatment which had a 
completion rate of 45.5 percent; and 

• 73.8 percent of admissions were to non- 
residential services which had the lowest 
completion rate of 39.1 percent. 7 
(Figure 7.M) 



Source: CASA analysis of The Treatment Episode Data Set (TEDS), 
2009. 



Figure 7.M 

Percent of Treatment Admissions and 
Completions by Different Types of 
Treatment Service Venues, 2008 



54.8 



I Admissions 
1 Completions 



73.8 



14.8 



11.4 



45.5 



□ 



39.1 



Short-Term Residential 
Services 



Longer-Term 
Residential Services 



Non-Residential 
Services 



Source: CASA Columbia analysis of The Treatment Episode 
Data Set, Discharges (TEDS-D), 2008. 



Most recent available data on discharges. 
' Specifically, those that received state funds and 
reported data to TEDS. Data include only those 
discharges that could be linked to admission data in 
the 2008 TEDS dataset. The general completion rate 
among all discharges (regardless of whether they 
were linked to admission data) was 42.1 percent. 
* All parts of the treatment plan or program were 
completed. 



-145- 



Of those discharges that did not represent a 
completed treatment episode, 46.6 percent 
dropped out of treatment, 25.9 percent were 
transferred to another treatment service (whether 
or not the patient attended that program is 
unknown), 12.8 percent were terminated by the 
program and 4.5 percent were incarcerated. The 
remainder failed to complete treatment for some 
other reason.* 77 

Variations in Treatment Completion by 
Source of Referral 

Admissions to addiction treatment for which the 
source of referral was an employer were the 
most likely to complete treatment (57.2 percent 
of admissions), followed by referrals from the 
criminal justice system (48.1 percent). 
Admissions referred by health care providers 
and individual sources-including concerned 
family members, friends and the self-referred- 
were the least likely to complete treatment (34.6 
percent and 33.9 percent of admissions, 
respectively). 78 Concern about potential loss of 
a job or criminal sanctions might help account 
for higher rates of treatment completion among 
those referred by employers or the criminal 
justice system. (Table 7.2) 

Table 7.2 

Treatment Completion by Source of Referral 



Source of Referral 


Percent 


Total 


42.1 


Employers 


57.2 


Criminal Justice System 


48.1 


Addiction Treatment Providers 


44.5 


Schools 


41.1 


Community Sources 


36.6 


Health Care Providers 


34.6 


Individual Referrals 


33.9 



Source: The Treatment Episode Data Set (TEDS) 
discharge data, 2008. 



Variations in Treatment Completion by 
Primary Substance Involved 

Patients admitted to treatment with addiction 
involving alcohol as the primary substance had 
the highest rate of treatment completion (50.7 
percent) compared with 39.3 percent involving 
marijuana, 35.4 percent involving other illicit 
drugs and 35.3 percent involving prescription 
drugs. The treatment completion rate for 
admissions involving multiple substances was 
38.9 percent 



79 



Variations in Treatment Completion by Key 
Patient Characteristics 

Male patients admitted to treatment were likelier 
than females to complete treatment (48.5 percent 
vs. 42.6 percent of admissions). No significant 
age-related differences in treatment completion 
were found. 80 With regard to racial/ethnic 
differences in treatment completion, Hispanics 
admitted to treatment were more likely to 
complete treatment than were whites or blacks 
(46.8 percent vs. 37.9 percent and 35.4 percent 
of admissions, respectively).' 81 

Link between Funding Source, 
Type of Service Provided and 
Treatment Completion 

Individuals who are privately insured are 
substantially less likely to enter addiction 
treatment than those with public insurance.* 82 
Publicly-funded admissions to addiction 
treatment are likelier than privately-funded 
admissions to be for more intensive services: 



i.e., moving, illness or hospitalization, death, other 
reason out of patient's control or the reason for 
discharge is unknown or not recorded. 



' Similarly, a study of patients receiving treatment for 
addiction involving alcohol found that black patients 
were less likely than white or Hispanic patients to 
complete their treatment program, regardless of 
whether they were enrolled in non-residential 
treatment (17.5 percent vs. 26.7 percent and 29.7 
percent, respectively) or residential treatment (30.7 
percent vs. 46.1 percent and 42.9 percent, 
respectively). 

* Controlling for type of substance, severity of the 
addiction, demographic characteristics, current health 
status and whether the individual is a daily cigarette 
smoker. 



-146- 



• intensive outpatient (25.9 percent vs. 15.1 
percent), 

• short-term residential (21.6 percent vs. 14. 1 
percent), and 

• longer-term residential (7.6 percent vs. 3.0 
percent). 83 

Privately- funded admissions are likelier than 
publicly-funded admissions to be to non- 
intensive outpatient services (67.6 percent vs. 
44.7 percent), have a higher rate of treatment 
completion (53.7 percent vs. 42.9 percent) and 
have a lower rate of transfer to another facility 
(12.2 percent vs. 17.9 percent). 84 

Existing data do not provide an explanation for 
these differences and no data are available on 
treatment needs and outcomes by funding source 
and type of service provided. Possible 
contributing factors, however, might include that 
privately-funded admissions are likelier to 
involve less severe cases of addiction, those with 
private resources may have greater access to 
effective support services or quality care, or 
those with private insurance may be less likely 
to seek treatment perhaps due to the perceived 
stigma. 

Barriers Patients Face in Accessing 
and Completing Addiction 
Treatment 

In addition to the limited private sector coverage 
of addiction treatment and the lack of treatment 
referrals from the health care system, many 
other barriers stand in the way of individuals 
accessing and completing addiction treatment. 
These include: a misunderstanding of the 
disease, negative public attitudes and behavior 
toward those with the disease, privacy concerns, 
cost, lack of information on how to get help, 
limited availability of services including a lack 
of physicians trained in addiction care, 
insufficient social support, conflicting time 
commitments, negative perceptions of the 
treatment process and legal barriers. Other 
factors having to do with treatment quality are 
discussed in Chapter X. Rarely is there only one 



obstacle to a person receiving needed 
treatment. 86 

Although comparable national data for barriers 
to accessing smoking cessation treatment are not 
available, research indicates that barriers similar 
to those facing individuals seeking addiction 
treatment involving alcohol or other drugs stand 
in the way of smokers accessing tobacco 
cessation services. 87 

Misunderstanding of the Disease 

One of the most frequently reported barriers to 
accessing addiction treatment has been described 
as patient denial. 88 However, what is commonly 
viewed as denial might also be characterized as 
a misunderstanding of the disease. As is the 
case for seeking treatment for other health 
conditions such as diabetes, hypertension or 
heart disease, 89 most cases of denial that serve as 
barriers to treatment access actually involve 
cases in which a person with symptoms of 
addiction does not recognize that he or she has a 
treatable disease, 90 underestimates the severity 
of the disease 91 or does not believe that the 
symptoms can be allayed through treatment. 92 
Such feelings stem not only from a lack of 
public awareness about the true nature of 
addiction— that it is a brain disease that can be 
treated effectively—but from the disease itself— 
one effect of addictive substances on the brain is 
that judgment, self-awareness and insight 
become impaired. 93 Continuing to misuse 
substances despite the associated harms is a 
defining symptom of the disease of addiction 94 
and in many cases results from the changes that 
addictive substances produce in the structure and 
function of the areas of the brain that control 
judgment, decision making and behavioral 
inhibition and control. 95 

In one survey of people with a history of 
addiction in their families, 60 percent cited 
denial as the biggest obstacle to getting help for 
addiction. 96 The majority (71.7 percent) of 
respondents to CASA Columbia's NAB AS think 
that a main reason why people with addiction do 
not get the help they need is that they refuse to 
admit to having a problem or that they do not 



-147- 



want to quit.* 97 Another study found that 
between eight and 1 6 percent of people who had 
been assessed but had not entered treatment 
cited some form of denial as the barrier. f 98 

The most frequently-mentioned barrier to 
accessing treatment for addiction involving 
alcohol and drugs other than nicotine is not 
being ready to stop using these substances. 1 99 A 
study of current smokers in Wisconsin found 
that the main barriers to quitting that participants 
reported were not being ready to stop smoking 
because they enjoy it (79 percent), would crave 
it (75 percent) or are afraid of losing the stress 
relief associated with it (63 percent). 100 

One national survey found that among 
respondents who needed 8 but did not receive 
treatment, only 3.3 percent of those with 
addiction involving alcohol, 8.3 percent of those 
with addiction involving another drug 
(excluding nicotine) and 12.4 percent of those 
with addiction involving multiple substances 
(excluding nicotine) perceived a need for 
treatment. 101 

Treatment providers also cite denial as the main 
barrier to treatment access: CAS A Columbia's 
survey of treatment providers in New York State 
found that 85.5 percent of program directors and 
84.9 percent of staff providers said that denial of 
an addiction problem "very much" stands in the 
way of people looking for needed addiction 

102 

treatment. 

Misunderstanding of the disease of addiction 
also is reflected in public policies and health 
care practices that fail to integrate treatment for 



Respondents were asked to select two or three 
reasons from a list read to them by the interviewer. 
' Eight percent of respondents believed their "drug 
use is not causing any problems" while 16.1 percent 
believed they "could handle their drug use on their 
own." 

* As reported in a national survey of individuals ages 
12 and older who recognized they needed treatment, 
made an effort to get treatment, but did not receive 
treatment. These estimates are from combined 
national data from 2006-2009. 
§ Met clinical diagnostic criteria for addiction 
involving alcohol or drugs other than nicotine. 



all addictive substances including nicotine into 
standard treatment protocols. (See Chapter X.) 

Negative Public Attitudes and Behaviors 
Toward People with Addiction 

Related to widespread misunderstanding of the 
disease of addiction is the stigma attached to it— 
the well documented, strong disapproval of or 
discrimination against those with the disease— 
and the fear of repercussions which prevent 
people with addiction from getting help. 103 
Although stigma is a subjective experience- 
perceived disapproval by others and subsequent 
embarrassment may or may not reflect a more 
objective reality— there is a long history of 
blaming and looking down on people with 
addiction 104 rather than sympathizing with them 
as we do for those with other health conditions. 
The fear of disapproval or rejection can derive 
from an individual's own low self-esteem or 
sense of shame about having addiction or it can 
derive from a fear of abandonment by friends or 
family because of the substance use itself, the 
consequences that result or because of the 
decision to pursue treatment. 105 

Twenty-nine percent of the respondents to 
CASA Columbia's NABAS reported that the 
main reason why people with substance-related 
problems do not get the help they need is a fear 
of social embarrassment or shame. 106 Another 
national survey found that two-thirds (67 
percent) of the public believe that a stigma exists 
toward people who have been treated for 
addiction involving alcohol or other drugs." 107 
A related study found that 80 percent of the 
public believes that there is a stigma against 
people with addiction involving alcohol and 5 1 
percent believe this stigma is maintained even 
after treatment or cessation of alcohol use. 108 

Smokers also face a stigma, particularly in light 
of increasing anti-smoking policies and 
awareness of the health risks of smoking and 
exposure to environmental tobacco smoke. 109 



This survey excluded addiction involving nicotine. 
Stigma was defined for respondents as "something 
that detracts from the character or reputation of a 
person; a mark of disgrace." 



-148- 



One survey of New York City residents found 
that 39 percent said that "Most people think less 
of a person who smokes" and 21 percent said 
that "Most people believe smoking is a sign of 
personal failure." 110 

Over 40 percent (4 1 .4) of respondents to the 
NABAS reported that discrimination against 
people in recovery from addiction involving 
nicotine, alcohol or prescription or illegal drugs 
is a very (15.8 percent) or somewhat (25.6 
percent) serious problem in their community; 
51.0 percent of those who had their own history 
of addiction thought it was a very (24.5 percent) 
or somewhat (26.5 percent) serious problem. 111 

Thirty-eight percent of the respondents to the 
NABAS reported that the main reason why 
people with addiction do not get the help they 
need is a fear of adverse consequences like 
losing a job, getting expelled from school or 
losing child custody. Treatment providers also 
see this as a barrier to treatment access: CASA 
Columbia's survey of treatment providers in 
New York State found that a significant 
proportion of the respondents said that the fear 
that one will be discriminated against 
"somewhat" (48.2 percent of program directors 
and 5 1 .4 percent of staff providers) or "very 
much" (39.8 percent of program directors and 
30.4 percent of staff providers) stands in the way 
of people looking for needed addiction 
treatment, as does fear of losing one's job (96.3 
percent of directors and 94.2 percent of staff 
providers said this "somewhat" or "very much" 
stands in the way of people looking for needed 
treatment). 112 

Another recent study found that while there are 
no significant differences in employment rates 
between people with a history of addiction and 
those without, those with a history of addiction 
report significantly higher rates of involuntary 
job loss. The analyses conducted for the study, 
which controlled for other factors that predict 
employment outcomes, suggest that employer 
discrimination may be an important contributing 
factor to job instability in this population. The 
authors speculate that while the Americans with 



Defined as effectively managing their disease. 



Disabilities Act of 1990 is successful in 
protecting those with a history of addiction from 
experiencing discrimination in the hiring 
process, it might be less successful in protecting 
those people from job termination. 113 

Individuals with a lifetime diagnosis of 
addiction involving alcohol are less likely to 
access treatment or support services f if they 
perceive that addiction carries a stigma. 114 

Respondents to the NABAS admit that they 
would discriminate against people who have a 
history of addiction, being less likely to hire 
former smokers or those in recovery from 
addiction involving alcohol or other drugs. 115 

• 53.6 percent of respondents said that they 
would be less likely to hire a qualified 
applicant upon learning that he or she is in 
recovery from addiction involving illicit 
drugs; 

• 41.1 percent would be less likely to hire a 
qualified applicant in recovery from 
addiction involving controlled prescription 
drugs; 

• 27.9 percent would be less likely to hire a 
qualified applicant in recovery from 
addiction involving alcohol; and 

• 6.6 percent would be less likely to hire a 
qualified applicant who is a former 
smoker. 116 

In comparison, 18.0 percent said they would be 
less likely to hire a qualified applicant who had 
been treated for depression, about nine percent 
said that they would be less likely to hire a 
qualified applicant who had been treated either 



1 Defined in this study as including services delivered 
in an inpatient ward, outpatient clinic, rehabilitation 
program, halfway house, emergency room or crisis 
center or by a private physician, psychiatrist, 
psychologist, social worker or other professional; 
alcohol or other drug detoxification; and self- 
help/mutual support programs (e.g. AA) or social 
services (family services or services delivered by an 
employee assistance program or by clergy). 



-149- 



for obesity or heart disease and about five 
percent said the same for diabetes, asthma or 



cancer/ 117 (Figure 7.N) 



Figure 7.N 

Participants Reporting They Would Be Less Likely* 
to Hire a Qualified Candidate in Recovery 
from/Treated for Each Condition: 



Addiction-Illicit Drugs 
Addiction-Prescription Drugs 
Addiction-Alcohol 
Depression 
Obesity 
Heart Disease 
Smoking 
Diabetes 
Asthma 
Cancer 



53.6 



41.1 



■ 27.9 



I 18.0 



9.4 

9.2 



I 6.6 

5.4 
4.8 
4.7 



* Among those who responded "somewhat less or much less likely 1 
Source: CASA Columbia National Addiction Belief and Attitude 
Survey (NABAS), 2008. 



Another study found that 43 percent of the 
public would be less likely to vote for a 
gubernatorial candidate who was in recovery 
from addiction involving alcohol or other drugs 
(excluding nicotine). 



Perhaps because of the lingering view that 
addiction results from lack of will power or self 
control that can be remedied with a simple 
change of mind, stigma and 
discrimination against addicted 
individuals are all too common. 
Recent research finds that people 
with addiction are seen as more 
blameworthy and dangerous 
compared to individuals with a 
"mental" illness, and those with 
a "mental" illness are viewed 
more negatively than those with 
a "physical" illness. 
Consequently, those with 
addiction are avoided more and 
helped less. 121 Research also 
indicates that enhancing the 
public's understanding of 
addiction or mental health 
disorders as having a 
neurobiological basis relates to 
increased public support for providing treatment 
services to individuals with these conditions, but 
has not yet translated into less of a stigma or 
discrimination associated with these 
conditions. 



P 
E 
R 
C 
E 
N 
T 



122 



118 



Discrimination against those with addiction is 
manifested on the governmental and institutional 
levels as well. Insurance companies generally 
provide less coverage for addiction treatment 
services than for other medical services. 119 
Although the passage of the Paul Wellstone and 
Pete Domenici Mental Health Parity and 
Addiction Equity Act (MHPAEA) of 2008, and 
the subsequent 2010 Patient Protection and 
Affordable Care Act, were significant 
breakthroughs, the laws contain exemptions and 
loopholes that may continue to limit access to 
addiction treatment. 1 120 



The stigma associated with addiction is 
compounded by its high rate of co-occurrence with 
mental illness. 

' For example, MHPAEA does not require health 
insurance plans to offer coverage for mental health or 
addiction treatment services, employers with fewer 
than 50 employees are not covered by the law, and if 
the projected cost increase is too high for health 



Privacy Concerns 

Because of negative public attitudes toward 
addiction and the consequent potential for 
stigma and discrimination, prospective patients 
for addiction treatment may have concerns about 
the extent to which their identity and the details 
of their treatment will stay private and 
confidential. 123 

Prospective patients sometimes believe that 
providers violate patients' confidentiality. 124 

insurance plans (more than two percent in the first 
year and more than one percent in subsequent years), 
then insurance companies may request an exemption 
from the law. Under the ACA, mental health and 
addiction treatment services must be offered in 
individual and small group health plans as part of 
essential health benefits, but the scope of these 
benefits will likely vary by state. See Chapter VIII 
for a more complete discussion of health insurance 
coverage for addiction prevention and treatment 
services. 



-150- 



Privacy concerns are particularly acute in rural 
populations where patients may fear a lack of 
anonymity due to relatively smaller and more 
close-knit communities. 125 

Another element of privacy concerns involves 
the aversion of some individuals to key elements 
of the therapeutic process— participating in 
individual or group therapy where patients 
discuss personal or intimate details with 
therapists or with other patients. 126 In one study 
of individuals with addiction, 36.5 percent of 
respondents said they do not like talking in 
groups, 35.6 percent said they do not like to talk 
about their personal lives with other people and 
32. 1 percent said they do not like being asked 
personal questions. 127 In a study of risky alcohol 
users, 50 percent cited a combination of 
concerns about privacy, labeling, asking for help 
and sharing problems as a reason for not seeking 

1 28 

treatment. 
Cost* 

Cost is one of the most frequently-reported and 
long-standing barriers to receiving addiction 
treatment. 129 Approximately 50 million 
Americans, or 16.3 percent of the United States 
population, had no health insurance in 2010. 130 
Twenty-nine million insured people are 
underinsured' 131 perhaps prompting them to 
postpone needed treatment. People who are 
uninsured and underinsured not only have higher 
rates of chronic, relapsing addiction, 132 but also 
generally receive less preventive care, are at 
more advanced disease stages at the time of 
diagnosis, receive less treatment for health 
conditions and have higher mortality rates than 
those with comprehensive coverage. 133 

A 2009 national survey found that nearly half 
(49 percent) of U.S. adults feel that they would 
not be able to afford treatment for addiction 
involving alcohol or other drugs 1 if they or 



See Chapter VIII for a more complete discussion of 
cost-related issues in addiction treatment. 
' Those with health insurance, but with very high 
medical expenses relative to their incomes. 
* This survey did not address addiction involving 
nicotine. 



someone in their family needed it. This 
perception was true across income levels: 67 
percent of adults with annual incomes under 
$50,000 said they would not be able to afford 
treatment, as did 30 percent of those with 
incomes between $75,000 and $100,000 and 25 
percent of those with incomes above $100,000. 
In addition to those with the lowest income 
level, other groups most concerned about 
affording addiction treatment include those with 
a high school degree or less (65 percent), those 
living outside of metropolitan areas (56 percent) 
and adults ages 18-34 (56 percent). The survey 
also found that 75 percent believe that people 
with addiction may not get treatment because 
they lack insurance coverage or cannot afford 
it. 134 

Cost is a barrier to seeking treatment even for 
people with adequate health insurance. 135 Some 
addiction treatment programs do not accept any 
insurance payments— private or public— for their 
services, 136 and insurance coverage for addiction 
treatment, when it exists, often has higher co- 
pays and limited service coverage. 137 



With the current funding stream, you must be 
very rich or very poor to get treatment. 138 

—Johnny Allem 
Founder and President 
Aquila Recovery, Chartered 
Former President and CEO 
Johnson Institute 



People with private insurance tend to have 
greater concerns about cost and are likelier to 
cite cost as a barrier to treating addiction than 
people with Medicaid or Medicare. Those with 
public insurance focus more on accessibility 
issues (waiting times, eligibility) as barriers to 
treatment. 139 This disparity may be due to the 
fact that some private insurance companies do 
not cover addiction treatment and some 
employers do not extend their benefit plans to 
include addiction treatment coverage. 140 

Twenty-eight percent of respondents to the 
NABAS think that one of the main reasons why 
people do not get the help they need for 



-151- 



addiction is because of insufficient available and 
affordable treatment services. 141 Treatment 
providers see this as a barrier to treatment access 
as well: CASA Columbia's survey of treatment 
providers in New York State found that 
approximately 90 percent of the respondents 
said that inability to pay "somewhat" (44.6 
percent of program directors and 42.8 percent of 
staff providers) or "very much" (45.8 percent of 
program directors and 50.7 percent of staff 
providers) stands in the way of people receiving 
needed addiction treatment. 142 

Cost not only is a barrier to entering treatment, 
but to staying in treatment as well. One study 
found that people randomly assigned to receive 
free methadone maintenance therapy stayed in 
their treatment programs longer than those 
randomly assigned to fee-for-service treatment, 
even though the fee was only $2.50 per day. 143 

Lack of Information about How to Get 
Help 

A significant barrier to obtaining addiction 
treatment is the lack of knowledge about where 
to go for help and the limited ability of 
physicians, parents and other family members, 
teachers, coaches, employers, clergy and law 
enforcement to identify the signs of addiction in 
others and know how to help patients access 
effective treatment. 144 The NABAS found that 16 
percent of respondents believe that a main 
reason why people with addiction do not get the 
help they need is because of insufficient 
information about how and where to get help. 145 

Limited Availability of Services 

A significant barrier to treatment is the lack of 
appropriate and accessible treatment services. 146 
This barrier is due to insufficient training of 
medical professionals and treatment options and 
the lack of treatment options tailored to 
individual needs; excessively restrictive 
eligibility criteria in some treatment facilities; 
long waiting times for treatment entry and a lack 
of trained addiction physician specialists and a 
lack of inclusion of addiction medicine as a 
recognized field of practice by the American 



Board of Medical Specialties, as discussed in 
Chapters IX and X. 

Approximately half of respondents to CASA 
Columbia's NABAS reported that insufficient 
treatment programs and services for people with 
addiction is a somewhat or very serious problem 
in their communities. 147 Another national poll 
found that nearly half (47 percent) of the 
respondents said that treatment services are 
lacking in their community; only one quarter 
indicated that there are enough affordable, 
accessible quality treatment centers and 
services.* 148 CASA Columbia's survey of 
treatment providers in New York State found 
that a significant proportion of the respondents 
said that a lack of conveniently located treatment 
programs "somewhat" (62.2 percent of program 
directors and 56.8 percent of staff providers) or 
"very much" (17.1 percent of program directors 
and 21.6 percent of staff providers) stands in the 
way of people seeking needed addiction 
treatment. 149 

Some individuals who need addiction treatment 
face eligibility criteria for program entry that are 
too stringent-including a patient's ability to pay 
and a required agreement to comply with all 
rules and treatment protocols regardless of 
individual goals. 150 In contrast, the main 
criterion for treatment access in mainstream 
medicine is the principle of medical necessity, 
determined by a physician; 151 patients seeking 
medical treatment rarely have to meet a 
threshold level of problem severity or agree to 
comply in advance with particular rules, unless 
those rules are designed to protect the patient's 
health and safety (e.g., refusing to give a patient 
a certain medication that is contraindicated for 
medical reasons, requiring cessation of certain 
medications or behaviors prior to a surgical 
procedure). 



Those reporting the greatest concern about the 
limited treatment options in their communities 
included respondents with incomes below $50,000 
(52 percent), blacks (67 percent), those who knew 
someone with addiction (58 percent) and those who 
did not have health insurance (56 percent). 



-152- 



Patients who do meet eligibility criteria and are 
ready to enter treatment often face a long wait 
for services-according to some estimates, up to 
70 days 152 -due to limited treatment 
availability. 153 This barrier can undermine an 
individual's fragile resolve to enter treatment. 154 
Long waiting times may bias treatment entry in 
favor of those most likely to succeed with 
treatment, 155 as a longer wait time to enter a 
program is associated with pretreatment 
attrition. 156 One study found that the longer 
patients have to wait between clinical 
assessment and the first treatment session, the 
less likely they are to complete subsequent 
treatment sessions. 157 CASA Columbia's survey 
of treatment providers in New York State found 
that a significant proportion of the respondents 
said that long waiting lists "somewhat" (40.2 
percent of program directors and 49.3 percent of 
staff providers) or "very much" (22.0 percent of 
program directors and 21.0 percent of staff 
providers) stand in the way of people accessing 
needed addiction treatment. 158 

Insufficient Social Support 

A lack of social support can serve as a barrier to 
treatment access. Individuals with addiction 
may be discouraged openly by family or friends 
from entering treatment or may have more subtle 
fears that loved ones will think badly of them or 
will be embarrassed or ashamed if they enter 
treatment. 159 Even among those who may 
otherwise seek treatment, continued substance 
use in an addicted individual's family or social 
network can increase the risk of continued use, 
reduce the likelihood of treatment entry and 
derail treatment efforts. 160 

Conflicting Time Commitments 

Competing responsibilities and time 
commitments related to one's family and career 
are common reasons for not seeking 
treatment. 161 One study found that the 
opportunity cost of a person's time-including 
both time spent traveling to non-residential 
treatment programs and time spent in treatment 
that otherwise would be spent on work or leisure 
activities-is one of the main barriers to seeking 
treatment. 162 



Negative Perceptions of the Treatment 
Process 

Among those with addiction who accept that 
they need to treat their disease are those who 
believe they can manage it themselves, without 
professional assistance. 163 Such a belief may 
derive from a misperception of what symptoms 
and what level of symptom severity constitute 
the disease of addiction and require professional 
assistance, or it may derive from the belief that 
treatment simply is not effective and will not 
help. 164 Some of this concern may be warranted 
given the nature of the services offered. 
(See Chapter X.) 

Twenty percent of respondents to the NABAS 
think that a main reason why people with 
substance-related problems do not get the help 
they need is that they do not believe that 
treatment would help. 165 Treatment providers 
see this as a barrier to treatment access as well: 
CASA Columbia's survey of treatment providers 
in New York State found that a significant 
proportion of the respondents said that the belief 
that treatment does not work "somewhat" (63.9 
percent of program directors and 59.0 percent of 
staff providers) or "very much" (32.5 percent of 
program directors and 31.7 percent of staff 
providers) stands in the way of people looking 
for needed addiction treatment. 166 

Some individuals with addiction have negative 
perceptions or a fear of treatment providers and 
programs that may keep them from seeking and 
accessing treatment. 167 These perceptions can 
be based on an individual's prior negative 
experience in treatment, anticipation that the 
treatment process will be unpleasant, 
assumptions about the limited efficacy of 
treatment or a general fear of what might happen 
in treatment. 168 

With regard to smoking cessation, there is a 
prevalent belief among smokers that certain 
interventions, particularly nicotine replacement 
therapy (NRT), may not be safe. 169 One study 
found that 66.0 percent of current and former 
smokers expressed concerns about the safety of 
NRT; those expressing concern were less likely 



-153- 



to use NRT in a cessation attempt (30 percent 
vs. 49 percent). 170 

Legal Barriers 

Unlike other chronic health conditions, addiction 
involving illicit drugs, by definition, marks a 
person as having engaged in illegal activity. 
Treatment providers see this as a barrier to 
treatment access: CASA Columbia's survey of 
treatment providers in New York State found 
that a significant proportion of the respondents 
said that fear of being sent to prison or jail 
"somewhat" (41.0 percent of program directors 
and 42.8 percent of staff providers) or "very 
much" (42.2 percent of program directors and 
37.0 percent of staff providers) stands in the way 
of people looking for needed addiction 
treatment. 171 

Barriers to Treatment Access and 
Completion in Special Populations 

The barriers to treatment outlined above apply to 
most individuals with addiction; however, 
certain populations face additional barriers that 
exacerbate the difficulty of accessing needed 
treatment.* 

Individuals with Co-occurring Conditions 

An estimated 20 percent of the U.S. population 
has a disability that limits their functioning. 1 172 



The special populations discussed in this section do 
not necessarily mirror those discussed in Chapter VI 
since not all populations that require specialized 
screening or treatment protocols have barriers to 
treatment access that surpass or differ from those of 
the general population (e.g., individuals involved in 
the justice system). Likewise, not all special 
populations that have additional or unique barriers to 
treatment access necessarily require specialized 
screening or treatment protocols (e.g., rural 
populations). 

* Including individuals with sensory disabilities 
involving sight or hearing; physical disabilities that 
limit basic physical activities such as walking, lifting, 
carrying; mental disabilities that involve difficulty in 
learning, remembering or concentrating; or 
disabilities that impede self-care such as dressing, 
bathing or getting around. 



People with disabilities use addictive substances 
at nearly twice the rate of the general 
population. 173 While individuals with co- 
occurring addiction and mental health disorders 
such as anxiety and depression access treatment 
at higher rates than individuals in the general 
population (although most treatment facilities do 
not provide services tailored to this 
population), 174 those with other disabilities that 
impede functioning access treatment services at 
substantially lower rates than the general 
population. 175 

Many health and social service professionals fail 
to identify the presence of risky substance use or 
addiction in people with disabilities, 176 despite 
their high rate of substance use. 177 Many 
barriers stand in the way of treatment for people 
with disabilities, such as erroneous attitudes or 
beliefs of medical providers, 1 lack of staff 
training in how to work with disabled people 
and treatment methods and materials that are not 
tailored to the needs of people with 
disabilities. 178 People with disabilities who have 
addiction also may be deterred by 
accommodation barriers to treatment, such as 
lack of personal or public transportation to a 
treatment center 179 and facilities that do not have 
adequate accommodations, such as restrooms, 
parking facilities, hallways and ramps that are 
accessible to patients with mobility 

1 80 

impairments. 

Treatment personnel often do not have the 
proper training to meet the physical and other 
health care needs of patients with disabilities, 
such as knowledge of sign language or Braille. 181 
In 2009, 27.7 percent of facilities offered 
services in sign language for the hearing 
impaired. 182 



1 e.g., believing that people with disabilities deserve 
pity so they should be allowed more latitude to 
engage in substance use. 



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Pregnant and Parenting Women 

Barriers to treatment access and completion can 
be particularly acute for women who are 
pregnant or post-partum, despite the fact that 
pregnancy may provide substance-using women 
with the motivation they need to reduce their 
substance use or seek treatment. 183 In 2010, 
only 15.9 percent of facilities nationwide that 
provided addiction treatment services offered 
services specific to pregnant or post-partum 

184 

women. 

Limited availability of child care for parenting 
women in addiction treatment is a significant 
barrier to treatment entry and retention. 
National data indicate that only 6.5 percent of 
outpatient addiction treatment facilities that 
serve women offer child care, although facilities 
that served women only were significantly 
likelier than facilities serving both men and 
women to offer child care services. 185 

Some pregnant smokers report reluctance to quit 
smoking due to fear of weight gain, 186 not 
believing in the harmful effects of smoking to 
themselves or their fetus due to prior 
pregnancies with no observable harm and a 
social environment where smoking is 
prevalent. 187 

Some women also fear being branded as "bad 
mothers" by treatment personnel. 188 One study 
found that more than one-third of pregnant 
smokers reported being apprehensive about 
attending smoking cessation counseling because 
they believed the counselor would judge them 
harshly. 189 

Pregnant and parenting women might shy away 
from accessing treatment for addiction involving 
alcohol or other drugs (excluding nicotine) for 
fear that entering treatment may result in losing 
custody of their children; 190 they may be 
apprehensive of the involvement of child 
protective services if they were to be identified 
as having addiction. 191 CASA Columbia's 
survey of treatment providers in New York State 
found that a significant proportion of the 
respondents said that fear of losing child custody 
"somewhat" (25.3 percent of program directors 



and 37.0 percent of staff providers) or "very 
much" (73.5 percent of program directors and 
58.7 percent of staff providers) stands in the way 
of people looking for needed addiction 

1 9? 

treatment. 

Substance use during pregnancy is considered a 
form of child abuse under civil child-welfare 
statutes in 1 5 states and is considered grounds 
for civil commitment (i.e., forced admission into 
a treatment program) in three states. 193 Pregnant 
substance users have been charged with such 
crimes as fetal abuse, child abuse and neglect, 
delivering drugs to a minor, corruption of a 
minor, assault with a deadly weapon and 
manslaughter. 194 Some states have used prenatal 
substance use as grounds to terminate parental 
rights. 195 

Adolescents 

Few diseases affecting adolescents are as 
extensively under-treated as addiction, even 
though addiction is a disease with firm roots in 
adolescence. 196 The significant treatment gap in 
the adolescent population- which is particularly 
acute among black and Hispanic youth 197 -is due 
in large part to the failure to understand the 
developmental nature of addiction and the 
failure of health care professionals to look for 
and prevent risky substance use or to identify 
and address addiction in their adolescent patient 
populations. 198 

The Society for Adolescent Health and Medicine 
has called for greater access for adolescents and 
young adults to health care through 
nontraditional health care providers such as 
school health centers, community health centers 
and other public health agencies that rely 
primarily on public funding, and expanded 
insurance coverage. 199 Unfortunately, systems 
responsible for the welfare of young people- 
schools, juvenile justice, child welfare— too 
often miss opportunities to intervene with young 
people in need of treatment and continue to 
allow them to fall through the cracks undetected 
and unaided. 200 

Treatment models with a strong evidence base in 
adult populations are not necessarily applicable 



-155- 



to the treatment needs of adolescents with 
addiction. 201 Yet, effective evidence-based 
treatment approaches for adolescents do exist. 202 
Despite this, in 2010, only 28.8 percent of 
facilities nationwide that provided addiction 
treatment services offered adolescent-specific 

203 

services. 

Barriers to treatment for adolescents include 
lack of support among parents and school 
personnel and lack of interest on the part of 
adolescents in participating in treatment. 204 
These barriers may result in difficulty recruiting 
adolescents to participate in treatment. 205 One 
national survey found that adolescents frame 
their reasons for not wanting to participate in 
treatment as they "are not ready to stop 
substance use," "didn't want others to find out" 
and because they "could handle the problem 
without treatment"— barriers that are similar to 
those offered by the general population and are 
at least in part reflections of the disease itself 
and of the stigma attached to it. 206 Other barriers 
include insufficient research on the safety and 
efficacy of evidence-based addiction treatments 
for use in adolescent populations, particularly 
pharmaceutical therapies. 207 

Older Adults 

Older adults are less likely than younger people 
to be identified as having addiction or to be 
referred to treatment; 208 those who do try to 
access treatment often have difficulty finding 
age-appropriate treatment services. 209 In 2010, 
only 6.9 percent of facilities nationwide that 
provided addiction treatment services offered 
services specific to older adults. 210 

Older smokers, for example, may be less aware 
of the harmful consequences of tobacco use and 
may focus more on the perceived benefits, such 
as its use as an aid in coping with stress or 
controlling weight. 211 Some may feel that it is 
"too late" to reverse the effects of smoking and 
therefore may not be motivated to seek out 
smoking cessation services; this belief is 
reflected in the failure of many health care 
providers to counsel older adult patients to stop 
smoking and support them through a cessation 
attempt. 212 Some physicians may have concerns 



about the safety of prescribing pharmaceutical 
interventions for smoking cessation to older 
patients. 213 

Adults who develop late onset addiction 
involving alcohol are less likely than those with 
early onset addiction to have a family history of 
addiction (21 percent vs. 72 percent) and are 
more likely to try to hide their illness; further, 
the symptoms associated with addiction 
involving alcohol— such as disorientation or 
confusion-may be misinterpreted as cognitive 
or physical deficits such as dementia, depression 
or other medical problems common in the 
elderly. 214 

CASA Columbia's 1998 report, Under the Rug: 
Substance Abuse and the Mature Woman, found 
that when physicians were asked for five 
possible diagnoses of a hypothetical 68-year-old 
female patient with an array of complaints 
typical of risky use of alcohol or prescription 
drugs, only one percent identified a substance 
use problem as a likely diagnosis. Contrary to 
the evidence, only 62 percent of physicians 
reported believing that addiction treatment is 
somewhat or very effective for older women. 215 

The Homeless 

Mental illness and co-occurring addiction are 
highly prevalent in the chronically homeless 
population. 216 Addiction, like other health 
problems in the homeless population, too often 
goes unaddressed until it is severe enough to 
require costly urgent care and hospitalization, 
resulting in a great deal of unnecessary human 
suffering and a serious, yet avoidable burden on 
health care systems. 217 

Seeking addiction treatment may be a low 
priority for homeless individuals who must 
contend with the competing needs of securing 
food, clothing and shelter and who rarely have a 
network of social support to help them access 
and succeed in treatment. 218 Given homeless 
individuals' lack of resources, their ability to 
find appropriate treatment programs and pay for 



In a study of men ages 60 and older admitted to a 
VA geriatric outpatient treatment program. 



-156- 



services can be extremely limited. 219 However, 
even with greater motivation and better access to 
treatment, the environment in which many 
homeless people spend their time—with high 
rates of ambient substance use, crime and 
violence-may present additional barriers to 
seeking and receiving treatment. 220 

Lack of collaboration between social service 
providers, public health systems and addiction 
treatment programs is another significant 
obstacle to addressing addiction in the homeless 
population, resulting in a missed opportunity to 

22 1 

increase access to treatment. 

Homeless individuals, who frequently have co- 
occurring addiction and mental health disorders, 
often are rejected by community-based 
residential programs since housing programs for 
the mentally ill frequently exclude substance 
users, and those for substance users often 
exclude those with serious mental illnesses. 222 
One study found that 60 percent of homeless 
people who admitted to having addiction 
reported that they were not eligible for addiction 
treatment or subsidized housing. Forty-two 
percent of those who did receive treatment 
reported that their treatment was ineffective 
because of a lack of aftercare and housing 
services. 223 

Another study found that receipt of public 
insurance was the strongest predictor of access 
to treatment among homeless people relative to 
other predictors. Jail stays, emergency 
department visits and non-residential medical 
care visits were not associated with increased 
access to treatment, suggesting that referral links 
between these services and addiction treatment 
are not adequate. 224 

Veterans and Active Duty Military 

According to the U.S. Department of Defense's 
Task Force on Mental Health, service members 
may be concerned that their substance-related 
problems might impede their career 
advancement, which can lead them to avoid 
seeking timely care. 225 Soldiers may be 
reluctant to seek treatment for addiction because 
self-referrals can be reported to their superiors; 



the military has an established policy of 
reporting mental health and substance-related 
problems to superiors. 226 The use of illicit drugs 
or the misuse of controlled prescription drugs 
can be grounds for dishonorable discharge. 227 

Any referral for additional mental health care in 
a military treatment facility must be documented 
in an individual's personal record which can 
deter people from seeking such treatment. 228 
Data from 2007 show that since military 
operations began in Iraq, army commanders 
have dismissed more than twice as many 
soldiers for drug use than they did in the same 
period before the war. 229 Drug use is 
categorized as a form of "misconduct," which 
discontinues some or all military benefits. 230 

Another barrier to accessing treatment for 
veterans is the long wait time for initial 
appointments or between appointments. 231 
Veterans with co-occurring health problems also 
face barriers to treatment, including the practice 
of requiring individuals to be substance free 
prior to entering treatment for other co-occurring 
conditions that are common among military 
personnel, such as post-traumatic stress disorder 
(PTSD). 232 

More generally, there is a significant shortage of 
medical and mental health professionals to 
address the complex medical and psychological 
treatment needs of individuals returning from 
military combat, as well as those of their family 
members. 233 

Rural Populations 

Rural populations face a considerable gap in the 
receipt of needed addiction treatment. 234 
Limited accessibility to treatment services as a 
function of geographic location presents a 
significant obstacle to treatment access for 
people living in rural areas 235 since general 
medical and specialty treatment services 
typically are located in urban centers. 236 Only 
8.9 percent of all addiction treatment facilities 
are located in a rural county that is not adjacent 



The use of illicit drugs or the misuse of controlled 
prescription drugs. 



-157- 



to an urban county. In 2010, 8.9 million rural 
residents had no access to inter-city public 
transportation, 238 posing a significant barrier to 
treatment access. 

Rural residents tend to have lower incomes and 
are less likely than non-rural residents to have 
health insurance, which limits their ability to 
afford and pay for treatment. 239 And since rural 
residents are more likely than urban residents to 
be self-employed, they have fewer encounters 
with employee assistance programs. 240 For these 
reasons, rural residents who engage in risky 
substance use or have other health problems tend 
to delay seeking preventive care, resulting in the 
need for more costly care in the future. 241 

Native Americans 

National data on racial/ethnic differences in the 
addiction treatment gap are limited with regard 
to Native Americans due to small sample sizes 
for this population. 242 However, existing data 
suggest that Native Americans are the likeliest 
of all racial/ethnic groups to smoke and to meet 
clinical criteria for addiction involving alcohol 
and other drugs. 243 National data also suggest 
that the group with the largest treatment gap is 
Native Americans. 244 One estimate indicates 
that less than one-fifth of addiction treatment 
programs nationally offer specialty services for 
Native Americans. 245 



Chapter VIII 
The Spending Gap 

Despite the evidence that risky substance use 
can be identified and reduced through screening 
and early intervention, and that addiction can be 
treated and managed effectively with 
psychosocial and pharmaceutical interventions, 
financial investments in addressing risky 
substance use and addiction are aimed 
disproportionately at coping with the costly 
health and social consequences of the disease 
rather than at prevention and treatment. This 
spending gap impairs health and imposes 
extraordinary and unnecessary costs to 
taxpayers. The continued inadequacy of 
insurance coverage for these services further 
flies in the face of a fiscally-sound approach to 
disease prevention, treatment and management. 

The Rational Approach to Risky 
Substance Use and Addiction 

The goals of medicine are the prevention of 
disease, the diagnosis and treatment of illness or 
injury and the relief of pain and suffering. 1 The 
general standard for determining what health 
care services should be provided to patients is 
the "reasonable and necessary" 2 or the 
"medically necessary" standard. 3 The definition 
of what is considered necessary generally is 
made by health care payers based on the strength 
of the clinical evidence supporting the 
effectiveness of interventions in improving 
health outcomes. 4 In the Medicare and 
Medicaid programs, medical necessity is defined 
in various ways but generally as the prevention, 
diagnosis or treatment of illness or injury that 
endangers life, causes suffering or pain, causes 
physical deformity or malfunction or results in 
illness or infirmity. 5 Some states also require 
that Medicaid services not be more costly than 
reasonable available alternatives. 6 



See Chapters IV and V. 



-159- 



The American Medical Association (AMA) 
supports the ideal that all patients have "a basic 
right to available, adequate health care" 
regardless of the ability to pay. 7 This ideal is 
based on several arguments which assert a moral 
obligation to treat injuries or diseases that 
impede normal functioning.* 8 

Addiction is not unique as a health condition for 
which a lack of understanding of the nature of 
the disease and its causes has resulted in 
assigning blame to the patient and to inadequate 
or misguided interventions; other historical 
examples include tuberculosis, cancer, 
depression and HIV-AIDS. 9 However, once a 
body of evidence exists about the nature of an 
illness and how to address it, that information is 
incorporated into medical practice and 
reimbursement policies based on the obligation 
of the profession to treat disease. Addiction is a 
glaring example of practice lagging behind the 
science. 10 The science is unambiguous- 
addiction is a complex brain disease with 
significant behavioral characteristics 11 that 
results in unhealthy compulsive behaviors, 12 
diminished cognitive control, 13 clinically- 
significant impairment or distress 14 and that can 
lead to long-term disability and death. 15 Our 
continued failure to prevent and treat the disease 
is inconsistent with ethical standards and the 
goals of medical practice. 



The collective social protection argument posits that 
certain essential services, including safety and health 
care, are a "collective responsibility" of society and 
should be provided to all. The principle of fair 
equality of opportunity calls upon institutions to 
provide individuals with basic services needed to 
pursue the normal range of opportunities that are 
essential to a good life— to cultivate one's talents, 
develop skills and formulate one's own life goals. 



Costs of Our Failure to Prevent and 
Treat Addiction as a Medical 
Condition 

Risky substance use and addiction constitute the 
leading cause of death and disability in the 
United States. 16 The result of not providing 
effective prevention and treatment services for 
addiction is that the cost of addiction accrues, 
driving many other diseases, later manifesting as 
more expensive care and spilling out to costly 
social consequences. ' 

Looking just at government spending, CASA 
Columbia calculated that in 2005, 1 risky 
substance use- and addiction-related spending 
accounted for 10.7 percent of federal, state and 
local spending, and that for every dollar federal 
and state governments spent, 95.6 cents went to 
pay for the consequences of substance use; only 
1.9 cents was spent on any type of prevention or 
treatment. 5 The taxpayer tab for government 
spending on the consequences of risky substance 
use and addiction alone totals $467.7 billion a 
year, almost $1,500 a year for every person in 
America. 17 

The Largest Share of Costs Falls to the 
Health Care System 

The largest share of spending on the 
consequences of risky substance use and 
addiction is in health care. 18 Persons with 
addictive diseases are among the highest-cost 
health care users in America: 19 they have higher 
utilization rates, more frequent hospital 
admissions, longer hospital stays and require 
more expensive health care services. 20 Nearly a 
third (32.3 percent) of all hospital inpatient costs 
is attributable to tobacco, alcohol and other drug 
use and addiction. 21 

Even family members of individuals with 
addiction have approximately 30 percent greater 



f See Chapter III. 

* Most recent data available. 

§ In addition, 0.4 cents was spent on research, 1.4 

cents on taxation or regulation and 0.7 cents on 

interdiction. 



-160- 



health care costs compared to families with 
similar demographic characteristics who do not 
have a member with an addiction diagnosis. 22 

The health care costs associated with addiction 
also stem from the impact that addiction has on 
the ability to treat other diseases. Addiction 
affects the body in ways that complicate health 
care, for example, by weakening the immune 
system. 23 These costs, however, rarely are 
recognized. One study found that from 1 994 to 
2002, admissions of patients with addiction 
increased 46 percent but hospital costs increased 
134 percent; because only one percent of these 
patients had a primary diagnosis of addiction, 
the rise in costs was attributed to treating the co- 
occurring medical illness (i.e., the primary 
diagnosis). 24 

In 2010, only $28.0 billion (1.0 percent) of total 
health care costs was spent on addiction 
treatment-related services involving alcohol or 
drugs other than nicotine. Approximately $13.0 
billion was spent on treatment-related services 
involving alcohol and $15.0 billion on 
treatment-related services involving controlled 
prescription or illicit drugs.' 25 Total costs of 
treatment for addiction involving nicotine are 
unknown. 

In 2010, the U.S. spent $43.8 billion to treat 
diabetes 26 which affects 25.8 million people, 27 
$86.6 billion to treat cancer 28 which affects 19.4 
million people 29 and an estimated $107.0 billion 
to treat heart conditions 30 which affect 27.0 
million people, 31 but only $28.0 billion to treat 
addiction 1 32 which affects 40.3 million 
people. 5 33 



'Including medical, mental health and direct 
treatment costs. 

^ Treatment-related services include: detoxification 
(which is not considered treatment) and diagnostic 
and treatment services provided in inpatient settings 
(usually a hospital), outpatient/ambulatory settings 
(such as in a hospital outpatient department or 
emergency department and in physicians' and other 
medical professionals' offices and clinics) and 
residential settings (24-hour care). 
* There are no national data that document spending 
on treatment for addiction involving nicotine; 
although the cost estimate of $28.0 billion applies to 



Cost Savings of Addiction 
Screening, Intervention and 
Treatment 

There are no national data available on total 
health care spending for screening or 
intervention services;** 34 therefore, data on cost 
savings from these services and from addiction 
treatment come from individual studies rather 
than national data sets. 

In an effort to increase resources directed to 
screening, intervention and treatment, much 
attention has been focused on highlighting the 
cost effectiveness of these services. 35 While cost 
effectiveness certainly is an important 
component of resource allocation and targeting, 
this standard as applied to addiction is a stark 
reminder of the stigma attached to the disease. 36 
The United States does not use cost 
effectiveness as a measure to determine which 
health care treatments should be covered; in fact, 



the treatment of addiction involving alcohol and other 
drugs excluding nicotine, the prevalence estimate of 
those with addiction (40.3 million) includes those 
with addiction involving nicotine. 
§ Due to data limitations, the prevalence estimates for 
cancer and heart conditions include individuals ages 
18 and older who have ever been told by a doctor or 
other health professional that they have the condition 
(cancer/malignancy or a heart condition). The 
prevalence estimate for diabetes includes all ages and 
the estimate for addiction includes individuals ages 
12 and older; for diabetes and addiction, the 
prevalence estimates include both diagnosed and 
undiagnosed cases. In each case, total costs of 
treatment are included without regard to age. The 
cost estimates for treating diabetes, cancer and heart 
conditions were inflated to 2010 dollars using the 
medical inflation factor (7.9 percent) found in the 
Substance Abuse and Mental Health Services 
Administration's (SAMHSA) National Expenditures 
for Mental Health Services and Substance Abuse 
Treatment, 1 986-2005 publication. 

The 20 1 National Drug Control Strategy reports 
on spending in one grant program through SAMHSA, 
which spent $29.1 million in grants to eight states to 
provide screening, brief intervention and referral to 
treatment services in general medical settings, and to 
1 1 grant recipients to include training in these 
services in medical residency training programs. 



-161- 



almost no other disease is held to this standard. 
However, if cost-effectiveness were an essential 
factor in determining which medical services to 
fund, then screening, interventions and treatment 
for addiction certainly would be considered a 
good investment. 

One study found that the annual benefits in 
avoided health care spending (i.e., cost-saving) 
per person achieved through substance-related 
interventions in 200 1 dollars ranged from $634 
for brief physician interventions for risky 
drinkers to $3,951 for standard residential 
addiction treatment; the average annual savings 
per person was $1,939 across all interventions. 38 

The projected cost to insurers of offering 
comprehensive addiction treatment benefits also 
is modest. According to a 1 999 study, the cost 
of providing managed,* comprehensive* 
addiction treatment benefits with low co- 
payments* and no annual limits was $5. 1 1 per 
member in 1996- 1997. 39 Adding managed, 
unlimited addiction treatment benefits to a plan 
that previously did not offer addiction treatment 
benefits would increase costs 5 only by an 
estimated 0.3 percent.** 40 In 2001, the 
Congressional Budget Office estimated that 
mandating parity for mental health and addiction 
treatment benefits would increase group health 
insurance premiums by 0.9 percent initially and 
by 0.4 percent in total after accounting for the 
market-driven responses of health plans, 
employers and workers to the higher 
premiums.' ' 41 Studies of the effect of mandated 
parity in Federal Employee Health Benefit Plans 
have concluded that total plan spending per 



Benefits carved out and provided by a large 
managed behavioral health care organization. 

* Including outpatient, intensive outpatient, inpatient 
and residential treatment. 

* $10 or less. 

§ Costs include payments to providers; administrative 
fees and profits are not included. 

Assuming annual Health Maintenance 
Organization (HMO) insurance premiums of $1,500 
per member. 

' r Market-driven responses include: reductions in 
employers offering and employees enrolling in 
employer-sponsored insurance, changes in the types 
of plan offerings and reductions in scope of benefits. 



member did not increase significantly while out 
of pocket expenses for those who received 
treatment benefits declined. 42 

Because cost-effectiveness research to date has 
for the most part focused on the cost savings of 
providing a particular service within a particular 
population, it is not yet possible to generate an 
overall estimate of the potential cost savings of 
screening all patients for all forms of risky 
substance use and providing appropriate 
interventions, or for assessing the need for 
treatment and providing these services. 
However, as the following examples reveal, the 
opportunity for cost savings is substantial. 

Screening and Early Intervention^ 

Cost-benefit studies of screening and brief 
interventions for tobacco and alcohol use among 
adults and pregnant women have demonstrated a 
range of potential costs savings. 43 Numerous 
studies have demonstrated that medical costs for 
patients with addiction increase significantly as 
these patients age, 44 implying that the greatest 
cost savings can be achieved by early 
intervention and treatment. §§ 45 In the health 
care field, treatment costs of up to $50,000 for 
each year of life saved are considered to be a 
worthwhile investment in health (i.e., cost 
effective); in specialty care, such as cancer, 
treatment costs of up to $200,000 may be 
considered cost effective. 46 

Smoking. Smoking cessation programs yield 
positive health outcomes at the low cost of 
$5,000 per healthy year gained*** 47 compared to 
$56,200 per year for Aspirin and statin therapy 



11 Research is presented related to screening and 
interventions for smoking and risky alcohol use. 
Comparable research related to other drug use is not 
available. 

§§ Cost-benefit studies calculate the total cost savings 
that result from providing treatment (sometimes 
called return on investment); whereas cost- 
effectiveness studies determine the treatment costs of 
extending a patient's life by one year, or per quality- 
adjusted life year (QALY), a year of perfect health. 

Cost effectiveness as measured by costs minus 
savings for each year of healthy life attributable to 
the intervention. 



-162- 



to prevent coronary heart disease, $191,635 
per year for diet/exercise to prevent diabetes in 
high-risk adults' and $30,619 per year for 
biennial mammograms to screen for cancer 
among women ages 50 to 79. 49 

Screening pregnant women who smoke can be 
especially cost effective, given that the smoking- 
attributable medical care needed by infants 
whose mothers smoked while pregnant is an 
estimated $367 million per year. 1 50 A one- 
percent reduction in the prevalence of smoking 
in the U.S. population, including among 
pregnant women, would reduce the number of 
low-birth weight births by 2,000, § resulting in 
$21 million in avoided direct medical costs. 
Continuing at that rate for another six years, 
more than 57,000 low-birth weight births could 
be prevented, saving $572 million. 51 

The American Legacy Foundation projected that 
a reduction in Medicaid costs of nearly one 
billion dollars** could be achieved by preventing 
the current cohort of 24-year-olds tf from 
smoking. If prevention and cessation efforts 
were successful in motivating all Medicaid 
recipients who smoke to quit, states' Medicaid 
expenditures would be, on average, 5.6 percent 
lower, resulting in a total of $9.7 billion in 
savings after five years. 52 

Risky Alcohol Use. Screening and brief 
intervention for risky alcohol use rank among 
the top most cost-effective prevention services 
available, 53 along with colorectal cancer 



For 45-year old men with a 10-year risk for 
coronary heart disease of 7.5 percent. The 
calculation includes the cost of medication plus 
medical care including care for adverse events (e.g., 
Aspirin-induced gastrointestinal bleeding and 
resulting morbidity and mortality). 
* Costs include individually-tailored diet and exercise 
plans, visits to a nutritionist and physical training 
sessions. 
*In 1996 dollars. 
§ Based on 1995 birth rates. 
** Over the cohort's lifetime. 
' r The researchers chose this age because nearly all 
smokers begin smoking before age 24, whereas 
younger smokers may still be experimenting with 
tobacco. 



screening, hypertension screening and influenza 
immunization. 54 

Research findings suggest that early 
interventions 8 for risky alcohol use may result 
in health care cost savings of up to $43,000 for 
every $10,000 invested. 55 A study of primary 
care screening and brief physician intervention 
for adult risky drinkers yielded a net benefit of 
$947 per person. 56 

The use of screening and brief interventions in 
hospitals has demonstrated promising returns on 
investment. 57 A study of screening and brief 
interventions for risky alcohol use among adults 
in trauma centers estimated that over a three- 
year period, the cost savings associated with 
screening were $89 per patient 55 and the cost 
savings associated with brief interventions 
lasting 30 minutes were $330 per patient. In 
total, the implementation of a hospital-based 
alcohol screening and brief intervention program 
for risky alcohol use was estimated to reduce 
health care costs by $3.81 for every dollar 
spent. 58 Brief interventions" ' with adolescents 
ages 1 8 and 1 9 who were admitted to a trauma 
center for alcohol-related injuries also have been 
found to be more cost-effective than standard 

59 

care. 

The return on investment in preventing Fetal 
Alcohol Syndrome (FAS) further underscores 
the importance of screening and early 
interventions. The added medical costs for a 
child with FAS are estimated to be more than 
$2,300 per year for the first 21 years of a child's 
life. An alcohol intervention program costing 
$50,000 that could successfully prevent at least 
one case of FAS annually would pay for itself in 
just six years. 60 



11 Consisting of two doctor visits and two nurse 

follow-up calls. 

§§ Cost per screening was $16. 

Cost per intervention was $38. Savings were 
calculated based on average hospitalization and 
emergency department costs; hospital recidivism 
rates for trauma patients with and without addiction 
involving alcohol; and the efficacy rate of screening, 
brief interventions and referrals to treatment at 
reducing injury, recidivism and hospital readmission. 
' u Using motivational interviewing. 



-163- 



Addiction Treatment and Disease 
Management 

Persons with untreated addiction have higher 
health care utilization rates and more frequent 
hospital stays, generating billions of dollars 
in largely avoidable health care charges. 61 
Addiction treatment, particularly evidence-based 
treatment, not only reduces health care costs in 
both the short and long term, it saves lives and 
reduces other social consequences and costs as 
well* 62 Some research suggests that treatment 
"pays for itself," often on the day it is delivered 
and the total cost savings from addiction 
treatment continue to accrue over time. 63 

While the total economic benefits of treatment 
are greater than the cost of treatment, 64 
administrators and policymakers too often 
disregard benefits of treatment that accrue 
beyond the narrow silo of each individual 
government program. For example, health care 
payers may refuse to acknowledge the 
significant cost savings that may accrue outside 
the health care system (increased productivity, 
reduced crime, etc.). An example of this can be 
seen in an analysis of data from the VA health 
care system from 1998 to 2006 showing that 
providing addiction treatment resulted in an 
overall increase in health care costs, presumably 
because expanding access to treatment brought 
more sick patients into the health care system 
and more of their co-occurring medical 
conditions subsequently were identified and 
treated. The one exception was opioid 
maintenance therapy which paid for itself in 
health care savings. This study did not account 
for potential longer-term reductions in health 
care costs or for potential cost savings in other 
sectors because it was taking the perspective of 
an insurance payer— via the VA health care 
system 65 — and this perspective tends to look at 
short-term costs rather than long-term savings. 

Most studies— even those that look only within a 
particular system for costs and benefits— find 
immediate and longer-term savings associated 
with addiction treatment: 



The referenced studies do not include detailed 
examples of the nature of the treatment provided. 



• A longitudinal study of patients treated for 
addiction in Kaiser Permanente's Medical 
Care Program found an average reduction of 
30 percent in medical costs three years post- 
treatment. Significant declines were seen in 
areas such as the number of inpatient 
hospital days and emergency department 
visits, which are high-cost services. 66 

• A comparison of adult patients who met 
clinical criteria for addiction involving 
alcohol or drugs other than nicotine who 
were enrolled in an outpatient treatment 
program with a control group ' found that 
those enrolled in the treatment program were 
less likely to be hospitalized 1 8 months after 
treatment than before treatment. The study 
also found that treatment can cut health care 
costs associated with addiction by about one 
quarter, primarily by reducing the number of 
annual hospital stays and the likelihood of 
emergency room visits. 67 

• An analysis of data from patients in 
treatment for addiction involving alcohol or 
drugs other than nicotine in California found 
a benefit-cost ratio of more than seven to 
one'} the average cost of treatment was 
$1,583 and the benefits § were $1 1,487. 
Most of the savings were attributed to 
reduced crime and increased employment. 68 

• An analysis of statewide data from 
Washington State found that treatment was 
associated with an annual $2,500 reduction 
in medical expenses** among adult patients 



' Adults who met criteria for addiction involving 
alcohol or other drugs but did not receive treatment. 
* Nine months after treatment. 

§ Including earnings from employment and reductions 
in the costs related to emergency department visits, 
incarceration and crime. 

** Including inpatient and outpatient hospital care, 
physicians' services, prescription drugs and nursing 
home care. Most of the reductions in medical 
spending were within Medicaid expenditures. 



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with addiction receiving general assistance 
welfare. 69 A more recent analysis in 
Washington State of the return on 
investment from an increase in addiction 
treatment for disabled adults enrolled in 
Medicaid or medical coverage through a 
general assistance welfare program between 
2006 and 2009 found a savings of $2.07 in 
medical and skilled nursing facility expenses 
for every dollar spent on treatment' over the 
four-year period. 70 

• A performance audit of the costs and 
savings to the Colorado Medicaid Program— 
which in 2006, implemented a benefit to 
provide outpatient addiction treatment for 
services related to tobacco, alcohol and 
other drugs for all Medicaid beneficiaries- 
found that the program cost $2.4 million 
over the course of three years while medical 
costs for patients receiving services under 
this program declined by approximately $3.5 
million/ 71 

• A simulation of potential cost savings in the 
justice system demonstrated that treating all 
arrestees who are at risk of addiction would 
cost $13.7 billion and save more than $46 
billion (for every dollar spent on treatment, 
more than three dollars in benefits accrue). 
Treating all arrestees who are "probably 
guilty" 5 and who are at risk of addiction 
would result in a reduction in recidivism 
rates in the range of 16 to 34 percent, 
depending on the modality of treatment 
(with long-term residential treatment 
yielding the greatest reduction in recidivism, 
roughly 27 to 34 percent). 72 



Measured as receiving a clinical diagnosis of 
alcohol or other drug dependence or psychosis, 
receiving detoxification services or having been 
referred for alcohol or other drug assessment by the 
state division of alcohol and substance abuse. 

* In this study, treatment included outpatient, 
residential and opioid maintenance therapy and case 
management. 

* Analysis based on available Medicaid claims data, 
not a controlled longitudinal study. 

§ As phrased by the authors of the study who state 
that an admission of guilt generally is required for 
enrollment in court-monitored treatment. 



Addiction Involving Nicotine. One study 
found that 24.6 percent of adult depressed 
smokers who received six sessions of mental 
health counseling and up to 10 weeks of nicotine 
replacement therapy (NRT) with the patch were 
abstinent from smoking after 18 months; the 
total cost of treatment (smoking cessation 
services plus mental health care) was $9,580 per 
life year** gained. 73 

Following the implementation of Medicaid- 
covered pharmaceutical therapy for addiction 
involving nicotine, Massachusetts had a 46 
percent annual decrease in hospitalizations for 
heart attacks and a 49 percent annual decrease in 
cases of coronary atherosclerosis. ft 74 

Addiction Involving Alcohol. For individuals 
with addiction involving alcohol, a number of 
pharmaceutical interventions have been found to 
be cost effective, including medical management 
with naltrexone therapy and combined 
naltrexone and acamprosate therapy. 75 

Even among patients who already have 
developed an alcohol-related illness (such as 
alcohol-related liver damage or psychosis), 
treatment may reduce future health care costs. 
Naltrexone therapy is related to less of an 
increase in health care expenditures for 
individuals with alcohol-related illnesses 
compared to a control group 1 * ($63 increase 
among naltrexone recipients vs. $814 increase 
among controls). Those in the control group 
were more likely to have an alcohol-related visit 
to the emergency department during the study 
compared to patients taking naltrexone (15 
percent vs. nine percent). 76 

Addiction Involving Other Drugs. One study 
examined the cost effectiveness of providing 



The cost of extending a patient's life by one year is 
a common metric used in cost-effectiveness studies. 
' 1 There were, however, no significant changes in 
rates of hospital admissions for respiratory conditions 
including pneumonia, asthma, chronic obstructive 
pulmonary disease and respiratory failure. 

Individuals with the same range of alcohol-related 
illnesses who were not prescribed naltrexone. 



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treatment to pregnant illicit drug users and 
calculated an average net savings of $4,644 per 
mother/infant pair. 77 

An examination of health care and pharmacy 
costs for patients with addiction involving 
opioids in a large U.S. health plan revealed that 
total health care costs (including inpatient, 
outpatient and pharmacy costs) six-months post- 
treatment were 29 percent lower for patients 
who received medication than for patients who 
received medication- free treatment ($10,192 vs. 
$14,353). 78 

A study of the cost effectiveness of short-term 
opioid replacement therapy' compared to 
detoxification only calculated a cost- 
effectiveness ratio of $1,376 in opioid 
replacement therapy costs per quality-adjusted 
life year (QALY). 79 Another study projected 
that methadone maintenance therapy costs 
$5,915 for every year of life gained.* 80 In HIV 
populations, expanding methadone maintenance 
capacity for heroin users is cost effective, at 
$8,200 per QALY gained in communities with 
40 percent HIV prevalence among injection drug 
users and $10,900 per QALY gained in 
communities with five percent HIV prevalence 
among injection drug users. 81 



Insurance Coverage of Addiction 
Treatment is Limited 

Recently-enacted federal and state parity laws 
have expanded coverage for addiction treatment 
where offered, and the Patient Protection and 
Affordable Care Act (ACA) holds potential for 
further expansion of access and benefits. 
However, insurance coverage of addiction 
treatment remains severely limited in both the 
populations and services that are covered. The 
absence of mandated coverage in all health plans 
means that some health plans may continue to 
choose not to provide coverage for addiction 
treatment, persisting to deny access to patients 
who need it. 83 

Parity Laws 

Federal and state parity laws require private 
insurers that provide mental health and addiction 
treatment services to provide them on par with 
medical services. In general, restrictions placed 
on addiction services (e.g., co-pays, deductibles) 
cannot be more restrictive than restrictions 
placed on other medical services. 84 

Specifically, while the Mental Health Parity Act 
(MHPA), passed in 1996, did not apply to 
addiction treatment, 85 the 2008 Paul Wellstone 
and Pete Domenici Mental Health Parity and 
Addiction Equity Act (MHPAEA) was enacted, 
in part, to address this omission. 86 The 
MHPAEA provisions apply to: 

• Plans sponsored by private and public sector 
employers with more than 50 employees and 
that include medical/surgical and mental 
health/addiction benefits; 5 



The use of evidence-based approaches in 
treatment will be driven by policy. We need to use 
the payment system to drive changes in practice? 2 

-Jeffrey Samet, MD 
Professor of Medicine and Social Behavior, 
Clinical Addiction Research and Education 
(CARE) Program 
Boston University School of Medicine 



One week of residential care followed by intensive 
outpatient (day treatment) services through labor/ 
delivery. 

' Patients, ages 15-21, received 12 weeks of 

buprenorphine -naloxone therapy and also were 

offered twice-weekly counseling. § Applies to plan years beginning on or after July 1, 

* Assuming annual treatment costs of $5,250. 2010. 



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• Medicaid managed care plans and 
benchmark/benchmark-equivalent plans ' 
that provide mental health/addiction 
benefits; and 

• State plans within the Children's Health 
Insurance Program (CHIP). 88 

Under the law, plans that offer addiction 
treatment benefits cannot impose limitations on 
these benefits that are more restrictive than 
limitations placed on medical and surgical 
benefits. 1 89 

In addition to the federal parity laws, 49 states 
and the District of Columbia have some type of 
parity law for mental health services; at least 38 
states include coverage addiction involving 
alcohol and/or other drugs. While the scope of 
these laws varies, some are stronger than 
MHPAEA. § 90 



This includes traditional and benchmark/benchmark 
equivalent managed care plans. In Medicaid 
benchmark/equivalent plans' benefits are determined 
by comparison to BlueCross/BlueShield, state 
employee benefit plans, certain Health Maintenance 
Organization (HMO) plans or benefits that include 
the basic services defined in Section 1937(b)(2) of 
the Social Security Act. 
1 The ACA extends certain MHPAEA parity 
requirements to Medicaid benchmark and benchmark 
equivalent plans that are not managed care plans that 
provide mental health or addiction treatment benefits. 
* The interim final regulations, which went into effect 
on April 5, 2010, address how health plans must 
comply with MHPAEA and how health plans may 
define covered services that are consistent with 
current medical standards. The regulations define 
classification of benefits (such as inpatient, in- 
network or prescription drug benefits); financial 
requirements (such as deductibles and out-of-pocket 
maximums); treatment limitations defined both 
quantitatively (limits on day visits or frequency of 
treatment limits) and qualitatively (standards for 
provider admission into a network or prescription 
drug formulary design); and how to determine 
whether these restrictions comply with the law. 
§ State parity laws generally fall into three categories: 
(1) mental health parity/equal coverage laws in which 
insurers must provide the same level of benefits for 
addiction treatment as they do for other health 
conditions; (2) minimum mandated mental health 
benefit laws in which some coverage must be offered 



A recent government evaluation found that post- 
MHPAEA, 96 percent of employers' plans 
continued to offer both mental health and 
addiction treatment services, two percent 
continued to cover only mental health services 
and another two percent discontinued their 
coverage of addiction treatment services. Plans 
also indicated that they had reduced service 
limitations on addiction-related services after 
MHPAEA. In general, patients' average cost- 
sharing burden declined after the MHPAEA, 
with the exception of co-payments for office 
visits which increased slightly. 91 (Table 8.1) 



Table 8.1 

Employers' Insurance Coverage of Addiction 
Benefits Since Enactment of the MHPAEA 





2008 Plan 
Year 


2010/2011 
Plan Year 


Employers including 
addiction benefits in 
most popular plan 


97% 


97% 


Employers placing 
limits on office visits 
for addiction care 


33% 


8% 


Employers placing 
limits on inpatient 
days for addiction care 


27% 


8% 


Average office visit 
copayment 


$25 


$27 


Average office visit 
coinsurance 


22% 


19% 


Average outpatient 
services copayment 


$39 


$33 


Average outpatient 
services coinsurance 


26% 


19% 



Source: United States Government Accountability 
Office. (2011). 



Analysis of national data found that in states 
with broad parity laws (where benefits for the 
treatment of addiction and mental illness are 
mandated in at least some health plans and must 
be offered at parity with medical and surgical 
benefits), there was a 12.8 percent increase 



but disparities in level of benefits provided are 
permitted; and (3) "mandated offering laws" in which 
an option of coverage for addiction treatment is 
offered and, if coverage is accepted, benefits must be 
equal with other health benefits. 



-167- 



between 1 992 and 2007 in total treatment 
admissions compared to states with weak parity 
laws (in which parity laws were absent or did 
not include addiction treatment services). In 
comparison, in states with limited parity laws (in 
which parity was mandated but with limitations 
such as applying to certain groups or a limited 
number of health plans), there was only a 4.7 
percent increase (compared to states with weak 
parity laws) in addiction treatment admissions 
during this time. 92 

Among adolescents who received both an 
addiction and psychiatric diagnosis, those living 
in a state with a parity law expanding coverage 
for addiction treatment are 4.5 times as likely to 
be diagnosed with addiction and 3.2 times as 
likely to receive treatment as adolescents in 
states without such parity laws. 93 

The Patient Protection and Affordable 
Care Act of 2010 

The Patient Protection and Affordable Care Act 
(ACA) of 20 1 was enacted to expand access to 
insurance for the uninsured, to make health care 
more affordable and to reform health care 
delivery systems to improve quality. 94 The 
federal government estimates that the ACA 
could expand coverage for addiction treatment 
to an additional 4.8 million Americans if 
coverage is offered at parity with other health 
benefits.* 95 



plans as part of an "essential health benefit" 
package. 97 The ACA also extends requirements 
of MHPAEA to some health plans to which the 
law did not previously apply/ 98 

One main goal of the ACA is to increase the 
number of people who have health insurance by 
making more people eligible for Medicaid, 99 
allowing individuals who do not have insurance 
through their job to obtain insurance in state 
exchanges (transparent and competitive 
marketplaces), offering them income-based tax 
credits and subsidies 100 and allowing young 
adults under age 26 to remain covered by their 
parents' insurance plan. 5 101 

The ACA also attempts to change the way health 
care is delivered to improve quality and integrate 
addiction treatment into medical care, for 
example through demonstration projects like 
Medicaid health homes, where teams of health 
professionals care for individuals with chronic 
conditions including addiction; 102 accountable 
care organizations (ACOs), in which groups of 
health professionals coordinate services for 
Medicare fee-for-service patients; 103 and through 
temporary funding to expand the role of 
community health centers. 104 If these initiatives 
are successful and become common practice, 
they will help to integrate the treatment of 
addiction into mainstream medical practice and 
expand the use of pharmaceutical therapies. 105 



The ACA has the potential for increasing access 
to addiction- related services by (1) increasing 
the number of people who are covered by health 
insurance 96 and (2) requiring that addiction 
treatment benefits be offered by certain' health 



This estimate was for those who buy coverage in the 
individual market, and while these plans must 
provide some form of addiction treatment as part of 
Essential Health Benefits, states have not yet defined 
their Essential Health Benefits. It is unclear how 
many states will include the full range of necessary 
services for addiction treatment in their definition. 
f Including new small fully-insured or self-insured 
plans, new individual market health plans, qualified 
health plans (as defined by the ACA), Basic Health 
Programs and Medicaid benchmark/equivalent plans. 



* The ACA requires that qualified health plans 
offered through the exchanges, individual (non- 
group) market plans and Medicaid non-managed care 
benchmark and benchmark-equivalent plans comply 
with MHPAEA. 

§ Even if they are married, in school or eligible to 
enroll in their employer's plan. Plans that existed on 
March 23, 2010 do not have to offer dependent 
coverage until 2014 if the dependent is eligible for 
employer-sponsored insurance. 



-168- 



Gaps in Coverage within Public and 
Private Insurance Plans Continue to 
Impede Comprehensive Addiction Care 

Screening and Interventions for Risky 
Substance Use. Recent developments in 
Medicare and Medicaid reimbursement have 
begun to remove some of the cost barriers that 
health professionals faced in routinely screening 
their patients for risky use of addictive 
substances and conducting early interventions 
when necessary. 106 

For example, the U.S. Department of Health and 
Human Services' Centers for Medicare and 
Medicaid Services (CMS) adopted Medicaid 
billing codes for screening and brief intervention 
services; in January 2007, these codes became 
effective. 107 The Medicaid codes cover these 
services related to alcohol and other drugs 
(excluding nicotine). 108 These codes are 
available for health care providers in individual 
states to use but there is no requirement for 
providers to use the codes. Individual states 
determine which services are reimbursed and, to 
be operational, states have to enable the billing 
codes; however, many have not done so.* 109 
With regard to smoking, the only screening 
services that states explicitly are required to 
provide are those that fall under the Early and 
Periodic Screening, Detection and Treatment 
(EPSDT) Program— the child health component 
of Medicaid which is required for each state to 
finance appropriate and necessary pediatric 
services, including tobacco cessation services 
for youth; as of2000, T 15 states explicitly 
require providers to screen youth for tobacco 
use. 110 (See next section on treatment for 
information about coverage for smoking 
cessation services.) 

In 2008, CMS adopted Medicare billing codes 
for structured assessments 1 and brief 
intervention services related to the risky use of 
alcohol and other drugs (excluding nicotine) for 



And these codes do not cover screening and 
intervention services for all addictive substances. 
' Most recent available data. 

* Structured assessments involve the use of validated 
tools such as AUDIT or DAST (see Appendix H). 



patients who show signs/symptoms of 
substance-related problems. 111 These services 
were reimbursed only when reasonable and 
necessary to diagnose or treat illness or injury. 112 
In October 201 1, CMS determined that 
Medicare would provide coverage in primary 
care settings 8 for preventive annual alcohol 
screening of all patients and up to four brief, 
face-to-face interventions for Medicare 
beneficiaries who screen positive for risky 
alcohol use but who do not meet clinical criteria 
for addiction involving alcohol. 113 Medicare 
does not reimburse for population-wide 
screening and brief interventions to address the 
risky use of illicit and prescription drugs because 
it is not yet recommended by the U.S. 
Preventive Services Task Force (see Chapter 
iV). tt 114 Although there are no specific 
Medicare codes for general tobacco use 
screening, questions about tobacco use are 
considered part of the medical history to be 
collected, for example, during the Initial 
Preventive Physical Examination for those new 
to Medicare. 115 As of August 2010, Medicare 
does cover preventive tobacco cessation 
counseling for smokers who do not present with 
signs or symptoms of tobacco-related disease. 
The benefit includes two individual tobacco 
cessation counseling attempts per year, with 
each attempt consisting of up to four sessions. 116 

Despite the facts that the American Medical 
Association (AMA) has published Current 
Procedural Terminology (CPT) codes for 
screening for tobacco use** 117 and risky use of 
alcohol and other drugs 118 and that most private 
insurance plans cover these services, 119 patients 
are not routinely screened for risky use or 
provided brief interventions if indicated. A 
2009 survey found that very few claims have 
been paid by commercial insurance plans for 



s Including outpatient hospital settings. 
** But not for other substances. Medicare allows 
providers to choose any screening tool that is 
appropriate for their clinical population and setting. 
' 1 Medicare does cover structured assessments to 
evaluate and provide interventions for patients who 
exhibit symptoms of addiction involving drugs. 

CPT codes for tobacco screening include the codes 
for "health and behavior assessment" and other 
preventive medicine services. 



-169- 



alcohol and other drug screening and brief 
intervention services. 120 Although 76 percent of 
smokers in commercial health plans reported 
being advised by their physician to stop smoking 
in a 2008 survey; only half recalled being 
advised about smoking cessation strategies or 
medications. 121 

The ACA was designed to increase the number 
of individuals covered under Medicaid and 
commercial insurance,* 122 but also allows states 
facing budget deficits to scale back eligibility 
under certain circumstances. f 123 Because of 
economic constraints, states appear to be cutting 
back on health services rather than assuring 
access to these services. 1 124 

An additional resource problem that stands in 
the way of screening and early interventions is a 
legal statute dating back to 1947, the Uniform 
Accident and Sickness Policy Provision Law 
(UPPL)} 15 Under the UPPL, insurers can deny 
payment for treatment of injuries sustained by a 
person under the influence of alcohol or other 
drugs. § 126 In states that adopted UPPL, EDs and 
trauma centers might not screen for risky 
substance use because reimbursement for the 
emergency or trauma services they provide 
could be denied; as a result, critical 
opportunities for intervention are missed. 127 
Because of the barriers the UPPL imposes to 



The ACA mandates no co-pay in private insurance 
and self-insured plans for alcohol screening and 
counseling; alcohol and other drug use assessments 
for adolescents; tobacco use screening for all adults; 
and cessation interventions for tobacco users. 
' States are permitted to scale back eligibility if they 
have expanded their Medicaid programs to non- 
pregnant, non-disabled adults with incomes over 133 
percent of the poverty level. 

* At least 3 1 states have implemented cuts that will 
restrict eligibility for health insurance programs 
and/or access to health care services. 
§ The law originally was adopted to control insurance 
costs at a time when little knowledge was available 
about addiction and when access to treatment was 
limited. The statute states: "The insurer shall not be 
liable for any loss sustained or contracted in 
consequence of the insured's being intoxicated or 
under the influence of any narcotic unless 
administered on the advice of a physician." 



needed screening and interventions for risky 
substance use, the AMA has been working to 
overturn the law and prohibit other state laws 
modeled on it.** 128 As of January 201 1, 25 
states still have the UPPL or a history of court 
decisions that permit insurers to use an alcohol 
exclusion to deny payment for treatment; 1 6 
states and the District of Columbia prohibit 
denial of benefits." 129 A similar legal provision 
allows many states to deny disability payments 
or workers' compensation to individuals harmed 
while under the influence of alcohol or while 
participating in an illegal act, such as driving 
under the influence. 130 

Treatment for Addiction. Current coverage of 
addiction treatment is not designed to prevent 
and treat the disease effectively. There is 
considerable variability in coverage within and 
among public and private insurance plans which 
poses significant barriers to treatment 
accessibility. 

Medicaid. The Medicaid program is the major 
public health coverage program for low-income 
Americans. 131 With the exception of the ACA's 
"essential health benefits" requirement/* 
addiction treatment services are not federally 
mandated in Medicaid, 132 nor are any addiction 
treatment services that are eligible for 
reimbursement defined at the federal level. 133 
However, states may provide addiction-related 
services under several of the mandatory benefit 
categories: 

• Physician services; 134 

• Inpatient services provided in a general 
hospital, such as inpatient detoxification, 135 
but not including room and board charges in 



In 2001, the National Association of Insurance 
Commissioners, which originally adopted the UPPL 
as a model law in 1947 and encouraged states to 
implement it, reversed their position and 
recommended the repeal of the UPPL. Since that 
time, several organizations along with the AMA have 
pledged support for repealing the UPPL. 
' r Other states do not explicitly permit or prohibit 
alcohol exclusion provisions. 
M Applies to Medicaid benchmark/equivalent plans. 



-170- 



residential specialty treatment settings or 
inpatient care for patients ages 22- to 64- 
years old in institutions for mental 
disease; 136 and 

• Outpatient hospital care,* including 
detoxification, individual, group or family 
counseling and/or psychotherapy, and 
diagnosis, treatment, assessment and 
medication management. 137 

Optional benefit categories under which 
addiction-related treatment services also may be 
provided include: 

• Outpatient rehabilitation services, including 
diagnostic and treatment services. States 
providing optional benefits under Medicaid 
often choose this option since it does not 
require services to be provided under the 
direction of a physician and instead permits 
the delivery of services including mutual 
support by community paraprofessionals and 



• Clinic services; and 

• Case management services. 140 

Last, states may provide addiction treatment 
services as part of a Medicaid managed care 
waiver program. 1 141 

Because state Medicaid plans vary widely in 
their eligibility requirements and benefits, 
individuals have substantially different access to 
care depending on the state in which they live. 
Some states cover a broad range of addiction- 
related services; others provide only a few and 

i • 142 

two states cover no such services. 

State Medicaid programs also distinguish 
between services offered for addiction treatment 



Several states specifically exclude addiction 
treatment from the outpatient services benefits and 
some place limits on the services such as number of 
visits per year. 

' A 2006 survey found that 3 1 states offer addiction 
treatment through a managed care waiver program. 



involving nicotine and treatment involving 
alcohol and other drugs. 

With regard to smoking, Medicaid plans are 
required to provide tobacco cessation counseling 
and pharmaceutical treatments to pregnant 
women, children and adolescents. States are 
free to choose whether or not to include tobacco 
cessation benefits for other enrollees. 143 In 
2009, 1 8 states covered individual counseling 
for all Medicaid enrollees, seven states covered 
counseling only for enrollees in some programs 
(fee-for-service or managed care) and six states 
covered it only for pregnant women. Eight 
states covered group counseling for all Medicaid 
enrollees, five covered group counseling only 
for enrollees in some programs (fee for service 
or managed care) and five states covered group 
counseling for pregnant women only. As of 
2009, 34 states covered the nicotine patch for all 
Medicaid enrollees, 33 covered bupropion, 32 
covered nicotine gum, 32 covered varenicline, 
28 covered nicotine nasal spray, 27 covered 
nicotine inhalers and 25 covered nicotine 
lozenges. 144 As of 201 1, six state Medicaid 
programs provide comprehensive coverage for 
smoking cessation treatments for all Medicaid 
enrollees, while five state Medicaid programs 
provide no coverage for cessation treatment for 
any enrollees. 145 

Medicare. Medicare is a federally-funded 
system for financing health care for U.S. citizens 
ages 65 and older and people under age 65 with 
certain disabilities. 146 Medicare covers the 
following services, when medically necessary: 

• Inpatient hospital services for detoxification 
for addiction involving alcohol and 
outpatient services for detoxification for 
addiction involving drugs other than 

147 

nicotine; 

• Inpatient rehabilitation treatment for 
addiction involving alcohol, controlled 
prescription drugs and illicit drugs in an 
acute care or psychiatric hospital; 148 

• Outpatient hospital-based diagnostic and 
therapeutic services for treatment of 



-171- 



addiction involving alcohol, and outpatient 
hospital services involving detoxification, 
rehabilitation and treatment for addiction 
involving drugs other than nicotine; 149 

• Clinic-based treatment services for addiction 
involving alcohol and detoxification services 
for addiction involving opioids, under 
physician supervision; 150 and 

• Tobacco cessation counseling from a 
qualified physician or practitioner for all 
smokers and tobacco cessation medications 
prescribed by a physician. 151 

Methadone maintenance therapy also is covered 
on an outpatient basis, but only when indicated 
for pain, and in hospitals for treatment of 
addiction involving opioids. 152 
Differences in copayments for outpatient 
addiction treatment and other outpatient services 
will be phased out by 20 14. 153 

Private Health Insurers. Historically, private 
health insurers have provided less coverage for 
the treatment of addiction than for other health 
conditions by setting lower annual or lifetime 
limits on benefits,' covering fewer inpatient days 
or outpatient visits and increasing cost sharing 
through higher deductibles and copayments. 154 
A survey of private health plans found that, 
while only 1 6 percent of private insurance 
offerings imposed lifetime limits on addiction 
treatment, 94 percent had annual limits for 
outpatient services and 89 percent had annual 
limits for inpatient services. Private insurance 
offerings were more likely to limit visits 
(outpatient) or days (inpatient) than to limit 
spending. 155 



Medicare covers two individual cessation 
counseling attempts per year, and each attempt may 
include up to four sessions. 
' Annual limits are caps that insurers place on the 
benefits an enrollee is entitled to each year. Limits 
can apply to particular services (e.g., 
hospitalizations), number of visits or dollar amount 
of covered services. Lifetime limits are caps on 
expenditures, on specific services or both during an 
individual's lifetime. 



Children's Health Insurance Program ( CHIP). 
Under CHIP, formerly the State Children's 
Health Insurance Program (SCHIP), states are 
entitled to federal matching funds up to specified 
limits to finance health care for low-income 
children 1 who do not qualify for Medicaid. 156 
States can provide benefits related to substance 
use and addiction under CHIP by expanding 
children's eligibility under Medicaid, by 
creating a separate insurance program or through 
some combination of these approaches. States 
that opt simply to expand their Medicaid 
programs are required to follow the rules and 
requirements of Medicaid. 157 States that provide 
benefits by creating unique CHIP programs 
(outside of Medicaid) must provide a benefits 
package equivalent to one of several 
"benchmark" insurance plans. § 158 States have 
latitude in designing their CHIP program. 159 A 
2000 study found that almost all states provided 
at least one of detoxification, inpatient/ 
residential or outpatient services, though many 
states imposed annual limits (e.g., 20 or 60 visits 
per year) or lifetime benefit limits (e.g., $16,000 
or $20,000). 160 

Gaps in Addiction Care Coverage Within 
Parity and Health Reform Initiatives. With 
regard to federal parity laws, MHPAEA includes 
an exemption if the financial burden of 
implementing the law is too great,** 161 and small 
employers (with less than 50 employees) are 
exempt from the law completely. 162 Under 
MHPAEA, insurance plans may cap services 



1 Through waivers, states may expand CHIP 
eligibility to pregnant women, low-income parents 
and adults without children. 
§ Such as the Blue Cross/Blue Shield Standard 
Option Service Benefit Plan offered under the 
Federal Employees Health Benefits Program 
(FEHBP), a plan that is available to the state's 
employees or a plan offered by the HMO with the 
largest enrollment in the state outside of Medicaid. 
States also may use a benefits package that is 
actuarially equivalent to one of the benchmark plans, 
an already existing state-funded plan or any other 
plan approved by the federal government. 

Health plans are exempt if complying with the law 
results in a cost increase of greater than two percent 
in the first plan year and greater than one percent in 
subsequent years. 



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(e.g., number of visits per year) as long as the 
caps are equivalent to those placed on medical 
services. 163 Placing blanket limitations on 
allowed visits or length of stay, however, does 
not accord with best practices for treating cases 
of addiction that are chronic and relapsing. 164 

Challenges to implementing MHPAEA in 
practice include a lack of education among 
medical professionals in how to screen, 
intervene and treat addiction and a lack of 
addiction physician specialists. 165 

With regard to state parity laws, self-insured 
employer-sponsored health plans are exempt 
from state regulation under the federal 
Employee Retirement Income Security Act 
(ERISA) of 1974. 166 Furthermore, coverage for 
mental health and addiction services varies 
dramatically by state, depending on the strength 
of the state's parity law. 

With regard to the ACA, despite the 
improvements in treatment coverage that will 
arise from its passage, many limitations remain 
both in policy and practice. Its impact on 
treatment access remains to be seen since many 
of the provisions of the law have not yet taken 
effect. For example, the expansion of Medicaid 
as a payer likely will result in reductions in 
federal and state grants for residential care 
(which is not covered by Medicaid). As a result, 
care may transition toward outpatient 
treatment 167 which may be inadequate in some 
cases, such as for treating patients with more 
severe addiction. 

Expanding access to insurance is necessary but 
alone is not sufficient to expand access to care. 
In 2006, Massachusetts enacted health care 
reform legislation similar to the ACA which, 
among other things, established universal health 
insurance through individual mandates to 
purchase insurance and government subsidies. 168 
In the years following, addiction treatment 
admission rates did not increase significantly. 
Despite the fact that the total uninsured 
population dropped to three percent, a large 
number (23-30 percent) of patients with 
addiction remained uninsured, either due to non- 
compliance with the mandate to obtain 



insurance, inability to pay even with subsidies or 
logistical barriers such as lack of documentation 
or a stable home address. For some of those 
who were successful in becoming insured, co- 
insurance and co-payments rendered treatment 
unaffordable. 169 Furthermore, expanding 
insurance coverage does not automatically 
translate into expanded screening and diagnosis 
by health professionals or capacity to treat large 
numbers of newly-insured patients. 
Similarly, requiring parity for addiction benefits 
in Federal Employee Health Benefit (FEHB) 
plans did not result in increased treatment rates. 
An analysis of nine large FEHB plans in the two 
years before and after the parity requirement 
found that the number of new diagnoses of 
addiction increased; however, utilization rates 
for addiction treatment benefits were 
unaffected. 170 

The ACA includes 1 categories of essential 
health benefits (EHB)— including addiction 
treatment-that must be provided by newly- 
created individual and small group plans. 171 Yet 
rather than defining what these services must 
include, the federal government has proposed 
that each state design its own EHB package,* 172 
meaning that benefits will vary across states. 
Furthermore, the EHB provisions do not apply 
to self-insured group health plans, large group 
market health plans or already existing small and 
individual market ("grandfathered") health 
plans. 173 The provisions that would expand 
coverage and require EHBs do not go into effect 
until 2014. 174 

Efforts to control spending and legal challenges 
may limit some intended effects of the ACA. 
States may respond to fiscal challenges by 
attempting to control costs in their Medicaid 
programs by cutting services. 175 Moreover, the 
ACA faces challenges in the U.S. Supreme 



* Within limits-the plan must be comparable to a 
benchmark plan: (1) the largest plan by enrollment in 
any of the three largest small group insurance 
products in the state's small group market; (2) any of 
the largest three state employee health benefit plans 
by enrollment; (3) any of the largest three national 
FEHBP plan options by enrollment; or (4) the largest 
insured commercial non-Medicaid HMO operating in 
the state. 



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Court over two provisions that would expand 
coverage: the Medicaid expansion and the 
requirement for individuals not covered under 
public programs or by employer-sponsored 
insurance to purchase insurance; the Court's 
decision would have implications not just for 
these provisions but for other parts of the law as 



For example, if the Supreme Court decides that the 
individual mandate is unconstitutional and not 
severable from the rest of the legislation, the entire 
ACA would be struck down. If it is deemed 
unconstitutional and severable, then the prohibitions 
against excluding patients with pre-existing 
conditions and charging higher premiums based on a 
person's medical history also might be invalidated. 



Chapter IX 

The Education, Training and Accountability Gap 



Compounding the profound gap between the 
need for prevention, intervention, treatment and 
disease management for addiction and the 
receipt of such care is the enormous deficit of 
trained providers; there is a wide gulf between 
existing knowledge about addiction and its 
prevention and treatment and the education and 
training received by those who provide or should 
provide care. In spite of the evidence that risky 
use of addictive substances is a public health 
problem and addiction is a disease: 

• Most health professionals* are not 
sufficiently trained to educate patients about 
risky use and addiction, conduct screening 
and interventions for risky use or diagnose 
and treat addiction; 

• Most of those who currently are providing 
addiction treatment are not medical 
professionals and are not equipped with the 
knowledge, skills or credentials necessary to 
prove the full range of evidence-based 
services to address addiction effectively;* 1 
and 



The term "health professional" as used in this report 
includes medical professionals (physicians, physician 
assistants, nurses and nurse practitioners, dentists, 
pharmacists) and graduate-level clinical mental 
health professionals (psychologists, social workers, 
counselors). All health professionals can be trained 
to educate patients about risky use and addiction and 
screen for these conditions; brief interventions also 
can be conducted by appropriately trained health 
professionals. Diagnosis and treatment requires a 
trained physician with the exception of psychosocial 
treatments which can be provided by trained 
graduate-level clinical mental health professionals 
working with a managing physician. 
1 The National Quality Forum (2005) defines 
evidence-based addiction care to include: screening, 
brief interventions, treatment planning, psychosocial 
interventions, pharmaceutical therapy, retention 
strategies and chronic care management. Effective 
implementation requires particular skills and training. 



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• Addiction treatment facilities and programs 
are not adequately regulated or held 
accountable for providing treatment 
consistent with medical standards and 
proven treatment practices. 2 

Further complicating the education, training and 
accountability gap in addiction treatment is the 
fact that there are no national standards; instead, 
there is considerable inconsistency among states 
in the regulation of individual treatment 
providers and of the programs and facilities that 
provide addiction treatment services.* 

For just about all known diseases other than 
addiction, treatment is provided within a highly- 
regulated health care system. In contrast, 
patients with the disease of addiction are 
referred to a broad range of providers largely 
exempt from medical training and standards (for 
many of whom the main qualification may be 
that they themselves have a history of addiction) 
who work within a fragmented system of care 
with inconsistent regulatory oversight. 

The Size and Shape of the 
Addiction Treatment Workforce 

Given the extensive prevalence of addiction in 
the U.S. and the frequently extensive treatment 
needs of individuals with addiction, there is a 
significant shortage of qualified addiction 
treatment providers. 3 According to data 
collected from 1996 to 1997, there are 134,000 
full-time staff and 201,000 total staff (including 
part-time and contract staff) working in 
addiction treatment. ' Only a small proportion of 
these workers, however, have medical training. 4 



Trained medical professionals and other 
graduate-level health professionals are less 
likely than other types of providers to work full- 
time in addiction treatment; rather, staff 
members with higher levels of education are 
more likely to be hired on a contract/part-time 
basis. 5 A nationally representative survey of 
addiction treatment facilities found that one- 
quarter of the program directors were not full- 
time employees; only two of the programs 
surveyed were directed by a physician; 54 
percent employed a part-time physician; less 
than 1 5 percent employed a nurse; and 
psychologists and social workers rarely were on 
staff. 6 An older study 1 found that medical 
professionals and graduate-level counselors each 
made up only about 17 percent of the full-time 
staff of addiction treatment facilities and that 
only 12.8 percent of facilities had a physician on 
staff full time. § 7 Another study found that more 
than a third of clinical supervisors lack any type 
of graduate degree. 8 

Unlike patient care in the mainstream medical 
system, which is delivered by highly educated 
and trained professionals, the staff primarily 
responsible for patient care in addiction 
treatment facilities is comprised largely of 
addiction counselors, many of whom while 
highly dedicated to addiction care have only a 
bachelor's degree or, in some cases, no post- 
high school education. 9 The Bureau of Labor 
Statistics reports that there were 76,600 
addiction counselors in 201 1." 10 One study 
found that 50 percent of facilities have full-time 
counselors on staff who have no degree; 58.5 
percent have a bachelor's level counselor, 61.9 
percent have a master's level counselor and 12.0 
percent have a doctorate level counselor. 1 1 



With the notable exception of the regulation of 
medication-assisted therapy for addiction involving 
opioids. 

* This estimate includes physicians, registered nurses, 
other medical personnel, doctoral level counselors, 
master's level counselors, counselors with other 
degrees, non-degreed counselors and other staff. 
Data on the numbers of professionals who currently 
are providing some type of addiction treatment are 
not available. 



* Data are from 1996/1997. 

§ 25.8 percent had a full-time registered nurse and 

17.5 percent had other full-time medical staff. 

Addiction counselors are those who "counsel and 
advise individuals with alcohol, tobacco, drug or 
other problems such as gambling and eating 
disorders. May counsel individuals, families or 
groups or engage in prevention programs." This 
estimate excludes social workers, psychologists and 
mental health counselors who provide these services. 



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Even among physicians, who constitute the 
group most qualified to treat patients with the 
medical disease of addiction, required training in 
addiction is minimal. 12 And there is a severe 
shortage of physicians with expertise in 
addiction treatment via the medical specialty 
fields of addiction medicine and addiction 
psychiatry. 13 

The American Medical Association (AMA) 
estimates that of the 985,375 active physicians, 
there are only 582 addiction physician 
specialists: 227 addiction medicine physicians 
and 355 addiction psychiatrists —the two 
medical sub-specialties specifically trained in 
addiction science and its treatment— totaling 
6/100ths of one percent of all active 
physicians. 14 However, according to the 
American Board of Addiction Medicine 
(ABAM), these estimates are low since they 
come from a voluntary, self-report survey in 
which physicians who choose to respond are 
asked to indicate their specialty and typically 
mark the field of their primary board 
certification rather than their subspecialty. 15 

Although there are no recent data identifying the 
actual number of practicing specialists in 
addiction medicine or addiction psychiatry, 
ABAM has certified 2,584 addiction medicine 
specialists and estimates that the number of full- 
time practicing addiction medicine specialists 
may be about five times the amount of the AMA 
estimate— approximately 1,200.' 16 This estimate 
still falls far short of the estimated minimum of 
6,000 full-time addiction medicine specialists 
currently needed to meet addiction treatment 
demands. 17 Even this projection of workforce 
need in addiction medicine may underestimate 
the need in several ways: (1) it does not include 
adolescents; (2) it does not include addiction 
involving nicotine;* (3) it does not include 
institutionalized individuals; (4) it assumes that 
only those who meet clinical criteria for 



Based on data from 2010. 
1 Data on the number of practicing addiction 
medicine specialists who are involved directly in 
patient care are not available. 
* Unless addressed in the context of addiction 
involving alcohol or other drugs. 



substance dependence as distinguished from 
substance abuse require any form of specialty 
care; and (5) it is based on data that are six years 
old. 18 Adjusting ABAM's estimate to address 
these gaps could increase substantially the 
number of addiction medicine specialists 
required to provide needed care. 

Likewise, due to the limitations of the AMA 
survey and the absence of other data, it is 
impossible to know how many of the 1,137 
physicians who are board certified in addiction 
psychiatry as of 201 1 19 currently are practicing 
in that subspecialty or how much overlap there 
is with the number of physicians certified in 
addiction medicine. 

Licensing and Credentialing 
Requirements for Individuals who 
Provide Addiction Treatment 5 

To help assure adherence to minimum standards 
in the delivery of medical care, the licensing and 
credentialing requirements of individuals who 
may provide such care are clearly delineated and 
regulated. For physicians, these include 
extensive graduate-level classroom-based and 
clinically-supervised training, a focus on 



s The information provided in this section is based on 
an extensive review of publicly available documents 
conducted by CASA Columbia in 2010. This 
entailed online reviews and updates (using the 
Internet and the Lexis/Nexis database) of publicly- 
available federal and state laws and regulations (in all 
50 states and the District of Columbia) and of 
professional association Web sites. CASA 
Columbia's analysis examined the minimum 
licensing and certification requirements to practice in 
each profession in the 50 states and the District of 
Columbia, and optional certifications. The analysis 
sought to develop a summary overview of the 
regulatory landscape. However, because licensing 
and certification requirements are found in a wide 
variety of laws and regulations and can change on a 
state by state basis, and may have changed in certain 
states since the time of the review, findings from this 
review cannot be guaranteed to be complete and 
current. Unless cited to another source, the findings 
presented regarding licensing and certification 
requirements are derived from this review. See 
Appendix A for a description of the methodology. 



-177- 



standards of medical practice and the adoption 
of evidence-based practices for those who wish 
to become board certified. 21 In contrast, there 
are no clearly delineated, consistent and 
regulated national standards that stipulate who 
may provide addiction treatment in the United 
States; instead, standards vary by payer and by 
state. 

In 2010, CASA Columbia examined the 
addiction-related licensing and certification 
requirements of individuals who most typically 
are the providers of addiction treatment and 
related services in the United States. These 
include medical professionals such as 
physicians, physician assistants, nurses and 
nurse practitioners; mental health professionals 
such as psychologists, social workers and 
counselors/therapists; acupuncturists; and 
addiction counselors. Licensure is a mandatory 
process required by state law; licensing 
standards are designed to ensure minimum 
competency required to practice one's 
profession and protect public health, safety and 
welfare. Certification is a voluntary process 
administered by non-governmental 
organizations, typically professional 
associations. 22 Certification demonstrates 
additional expertise within a specific area of 
one's profession (i.e., a specialty). 23 

Of all these groups, addiction counselors provide 
the majority of addiction treatment in the U.S. 24 
Indeed the only category of providers 
specifically required to be licensed to provide 
addiction treatment in most states is addiction 
counselors. Yet the requirements in some states 
for becoming an addiction counselor include 
only a high school diploma and some practical 
training-typically involving a focus on the 12- 
step model. 25 Training approximates an 
apprenticeship model which may fail to promote 
systematic adoption of evidence-based 
practices. 26 Historically, personal experience 
with addiction (i.e., being "in recovery") was the 
primary qualification necessary to become an 
addiction counselor. 27 

Unlike providers of medical care who are trained 
in evidence-based medical practices, few among 
the broad range of providers who may treat 



patients with addiction are trained in or 
knowledgeable about evidence-based practices 
in addiction prevention and treatment. 28 While 
medical professionals and some mental health 
professionals may have the training and skills 
needed to implement research-based treatments- 
-and regularly come into contact with patients in 
the target population of risky substance users 
and those with addiction—most are unprepared 
to address these conditions. And while 
addiction counselors, who constitute the largest 
proportion of the workforce in specialty 
treatment facilities, 29 specifically address 
addiction, most lack an education grounded in 
the science of addiction and are not equipped to 
deliver evidence-based treatments including 
appropriate medical care and treatment of co- 
occurring health conditions. 30 

Compounding this problem is that the diversity 
in education and training among the different 
types of individuals providing addiction 
treatment results in inconsistent treatment 
approaches and care for patients with 
addiction. 31 

Medical Professionals 

Medical professionals have been regulated at the 
state level since Colonial times. 32 Rooted in 
their police powers, states have the authority to 
prohibit the performance of ineffective and 
dangerous treatments, to license professionals 
and to define their scope of practice. 33 For 
specific licensing standards, states largely defer 
to professional boards and national organizations 
that accredit education programs. Medical 
professionals must complete an accredited 
professional education program and pass a 
national licensing exam to become licensed by 
the state in which they practice their profession. 
State licensing requirements may include 
minimum education, training or skills 
demonstrated by earning a specified degree; 
time spent in clinical training requirements; and 
passing a licensing exam. 

Because risky use of addictive substances is a 
public health issue and addiction is a medical 
condition, medical professionals-particularly 
physicians-should be on the front lines in 



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treating patients with these conditions, working 
with a team of other qualified health 
professionals. However, separate courses in 
addiction medicine rarely are taught in medical 
school 34 and there are no addiction medicine 
residencies among the 9,034 accredited U.S. 
residency programs currently training 1 16,404 
residents. 35 Physicians, therefore, lack the basic 
education and training in addiction medicine that 
is needed to understand the science of addiction, 
translate research evidence into practice, screen 
for risky use, diagnose and provide treatment for 
addiction and the broad range of co-occurring 
health problems, or refer patients to other 
specialists as needed. 36 

Physicians. To become a physician, an 
individual must earn a bachelor's degree, 
complete four years of medical school to earn an 
M.D. (allopathic physician) or a D.O. 
(osteopathic physician) and complete an 
additional three to seven years of post-graduate 
training in a medical residency training program 
(also called graduate medical education). 37 To 
become licensed to practice medicine, 
physicians must pass a three-step licensing 
exam; allopathic candidates take the United 
States Medical Licensing Exam (USMLE). 38 
The USMLE includes addiction as a possible 
subtopic in each step.* 39 Those who choose to 
practice osteopathic medicine must take the 
Comprehensive Osteopathic Medical Licensing 
Examination (COMLEX) administered by the 
National Board of Osteopathic Medical 
Examiners (NBOME). 40 Dimension 1 of the 
COMLEX exam is devoted to "Patient 
Presentation" where addiction is listed as a 
subtopic' 41 These requirements are set by 
national accreditation organizations (that 
accredit schools and residency programs) and 
professional boards (that provide education and 
licensing standards) to which states defer when 
they require professional licensing. 42 



Within the content areas "Central and Peripheral 
Nervous Systems: Abnormal Processes" in Step 1 of 
the exam, "Mental Disorders" in Step 2 and 
"Behavioral/Emotional Disorders" in Step 3. 
f Within the content areas "Population Health 
Concepts: Disease Detection and Monitoring" and 
"Cognition, Behavior, Sensory and Central Nervous 
Systems, Substance Abuse and Pain." 



Although physicians in the United States have 
extensive competency requirements regarding 
most illnesses, their level of required 
competency in addiction medicine is minimal 
given the prevalence of risky substance use and 
addiction in most patient populations. 43 No 
reliable national data exist on the proportion of 
medical school curricula devoted to the topic of 
addiction. A national survey of residency 
training program directors in seven medical 
specialties revealed that 56.3 percent of the 
programs report having required curriculum 
content in preventing and treating addiction, but 
that the median number of curricular hours of 
training ranges from three (emergency medicine 
and obstetrics/gynecology) to 12 (family 
medicine). 44 While most allopathic medical 
schools do include some addiction content in 
required coursework, 45 research suggests that the 
average school requires few hours of its four- 
year curriculum to be devoted to the topic. 46 

Physicians may choose to become board 
certified in a medical specialty, which 
demonstrates that they have the knowledge, 
skills and experience to treat patients within that 
specialty. 47 The American Board of Medical 
Specialties (ABMS) has adopted a Maintenance 
of Certification (MOC) program for all 
specialties in which physicians must stay abreast 
of the latest advances in their specialty and 
demonstrate use of best practices. 48 

CASA Columbia reviewed the board 
certification exam requirements of the six 
medical specialties that interact most often and 
regularly with patients who engage in risky 
substance use or have addiction to determine 
their addiction-related content: 



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• Internal Medicine- two percent of the 
general board exam. 49 In addition, 
substance use/addiction is listed as possible 
subtopics in the geriatric medicine* 50 and 
infectious disease 51 subspecialty exams; 
however, the exact proportions are not 
specified. 

• Pediatrics- 1.5 percent of the general 
exam, 52 five percent of the adolescent 
medicine exam 53 and two percent of the 
developmental-behavioral pediatrics 
subspecialty exam. 54 Substance-related 
topics also are listed in the pediatric 
emergency medicine, child abuse pediatrics, 
and neonatal-perinatal medicine 
subspecialty exams; however, the exact 
proportion is not specified. 55 

• Family Medicine-no specification in the 
general board exam, 56 but the pharmacology 
of and testing for the use of addictive 
substances is included as a possible subtopic 
in the optional sports medicine subspecialty 
certification exam. 57 

• Psychiatry— included as subtopics in the 
general board exam, but the proportion of 
the total content is not specified. 58 Also 
one-half percent of the forensic psychiatry 
and six percent of the psychosomatic 
medicine subspecialty exams are devoted to 
substance use/addiction. 59 Substance 
use/addiction also is listed as a subtopic in 



Subspecialty certifications in the same area may be 
offered by more than one medical board. For 
example, the geriatric medicine subspecialty 
certification administered by the American Board of 
Internal Medicine also can be obtained by physicians 
specializing in family medicine; the adolescent 
medicine certification administered by the American 
Board of Pediatrics also can be obtained by 
physicians specializing in internal medicine and 
family medicine; the pediatric emergency medicine 
exam administered by the American Board of 
Pediatrics also can be obtained by physicians 
specializing in emergency medicine; and the sports 
medicine subspecialty certification administered by 
the American Board of Family Medicine also can be 
obtained by physicians specializing in internal 
medicine, pediatrics and emergency medicine. 



the child and adolescent psychiatry, geriatric 
psychiatry and pain medicine subspecialty 
exams. 60 

• Emergency Medicine— included as a subtopic 
in the qualifying examination, although the 
exact proportion and content are 
unspecified. 61 

• Obstetrics/Gynecology— included in a 
subtopic of the general written board 
certification exam, although the exact 
proportion is unspecified. Substance 
use/addiction assessment and counseling are 
listed as one of 40 patient cases that may be 
covered in the oral exam. 62 The 
subspecialty of maternal- fetal medicine 
explicitly lists substance use/addiction as a 
competency for the certification exam, but 
the exact proportion and content are 
unspecified. 63 

There are two areas of specialty medical practice 
in addiction: addiction medicine and addiction 
psychiatry. 

Addiction Medicine. The American Board of 
Addiction Medicine (ABAM) offers a voluntary 
certification in addiction medicine to physicians 
across a range of medical specialties. 64 The role 
of the addiction medicine physician, as a 
member of an interdisciplinary team of health 
professionals, includes examining patients to 
establish the presence or absence of a diagnosis 
of addiction; assessing associated health 
conditions that are brought on or exacerbated by 
the use of addictive substances; participating in 
the development and management of an 
integrated treatment plan; prescribing and 
monitoring patients' use of addiction treatment 
medications and therapies; providing direct 
treatment and disease management for 
individuals with severe cases of addiction and 
providing consultation to other primary and 
specialty care providers. 65 To become certified 
in addiction medicine, applicants must meet 
specific educational and clinical requirements 
including: 



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• Graduating from a medical school in the 
U.S. or Canada approved by the Liaison 
Committee on Medical Education (LCME) 
or the Committee on Accreditation of 
Canadian Medical Schools (CACMS) or 
from a school of osteopathic medicine 
approved by the American Osteopathic 
Association (AO A);* 66 

• Being an ABMS board-certified physician 
or having completed a residency training 
program' in any medical specialty, plus 50 
hours of addiction medicine educational 
course work (continuing medical 
education/CME); 67 

• Completing at least 1 ,920 hours in teaching, 
research, administration and clinical care 
related to prevention and treatment for 
individuals who are at risk for or have 
addiction, or completing a one-year ABAM 
Foundation-accredited addiction medicine 
residency training program; 68 

• Passing a five and a half-hour computer- 
based examination; 69 and 

• Holding a valid and unrestricted license to 
practice medicine in the United States, its 
territories or Canada. 70 

Physicians must maintain their certification 
through ABAM's Maintenance of Certification 
(MOC) program of continuing education and 
periodic examinations. 71 



If applicants are graduates of medical schools 
outside the U.S. or Canada, they must have a 
currently valid standard certificate from the 
Educational Commission for Foreign Medical 
Graduates (ECFMG) or have passed the Medical 
Council of Canada Evaluating Examination 
(MCCEE). 

1 Residency programs must be accredited by one of 
the following: the Accreditation Council for Graduate 
Medical Education (ACGME), the Royal College of 
Physicians and Surgeons of Canada, the Professional 
Corporation of Physicians of Quebec or residency 
programs accepted by any member board of the 
American Board of Medical Specialties (ABMS) as 
qualifying to sit for that member board's certification 
examination. 



Though not yet a member board of the ABMS, 
ABAM is working to gain recognition of 
addiction medicine as a medical specialty. 72 

Addiction Psychiatry. The American Board of 
Psychiatry and Neurology, Inc. offers optional 
certification in addiction psychiatry. Addiction 
psychiatrists are trained to identify and treat co- 
occurring addiction and psychiatric disorders in 
individuals seeking treatment for either 
condition, and in therapies tailored to specific 
subgroups of patients with addiction. 73 
Addiction psychiatry is recognized by the 
ABMS. 74 Candidates for certification are board- 
certified psychiatrists who have completed a 
one-year fellowship in addiction psychiatry. 75 

Physician Assistants. Physician assistants are 
licensed to assist physicians in the practice of 
medicine, enabling them to perform many of the 
same duties that physicians perform, including 
medical assessments and prescribing 
medication. 76 The precise scope of their practice 
varies according to the regulations of each state. 

All states license and regulate physician 
assistants and require graduation from an 
accredited physician assistant's program and 
passing of the Physician Assistant National 
Certifying Examination (PANCE) administered 
by the National Commission on Certification of 
Physician Assistants (NCCPA). 77 States defer to 
the national accreditation agency and 
professional board for content requirements. All 
physician assistants must complete two years of 
college course work in basic and behavioral 
sciences and earn a degree from a program 1 
accredited by the Accreditation Review 
Commission on Education for the Physician 
Assistant (ARC-PA). 78 Most programs (more 
than 80 percent) award a master's degree. 79 



1 Physician assistant programs are approximately 27 
months long. 



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The ARC-PA requires physician assistant 
programs to provide some instruction in the 
"detection and treatment of substance abuse" 
although the nature and extent of this instruction 
is not specified. 80 The PANCE exam may 
include addiction in its psychiatry^ehavioral 
exam category.* 81 

As of 2010, all states permit physicians to 
delegate prescription privileges to physician 
assistants 82 and all states except Florida and 
Kentucky allow physician assistants to prescribe 
certain controlled substances under medical 
supervision. 83 Yet physician assistants, like 
other medical professionals, receive little 
training in addiction in spite of the fact that they 
can prescribe controlled substances. * 

Nurses. States offer several categories of 
licensing in the nursing profession, each with 
different standards, practice limitations and 
supervision requirements. As they do for 
physicians, states defer to national accreditation 
agencies and professional boards for specific 
licensing standards for nurses. To be a licensed 
registered nurse (RN), one must graduate from 
an accredited nursing program which includes 
earning either a bachelor's of science degree in 
nursing (BSN), an associate's degree in nursing 
(ADN) or completing a diploma program 
(administered in hospitals). 84 Graduates from 
each program are eligible to take the National 
Council Licensure Exam (NCLEX), 
administered by the National Council of State 



* Each question addresses one organ system along 
with one of seven practice areas: history taking and 
physical examinations, using laboratory and 
diagnostic studies, formulating a most likely 
diagnosis, health maintenance, clinical interventions, 
pharmaceutical therapeutics and applying basic 
science concepts. 

t A few states require physician assistants to be 
trained in addiction. Physician assistants in CA who 
wish to prescribe controlled substances without 
advanced approval from a supervising physician are 
required to take a controlled substance education 
course which includes assessment of risky substance 
use and addiction. In OK, all physician assistants 
must complete one hour of continuing education per 
year on the topic of addiction. 



Boards of Nursing, and they must pass this exam 
to become a licensed RN. 85 

Even though most nurses interact regularly with 
individuals who are risky users or who have 
addiction, 86 CASA Columbia's review found 
that in all but several states 1 addiction-related 
education is not required explicitly in curriculum 
guidelines for state nursing programs. Other 
research found that many nursing education 
programs do not teach current information 
related to addiction. 87 The National League for 
Nursing Accrediting Commission and the 
Commission on Collegiate Nursing Education, 
the two main accrediting agencies for nursing 
schools, do not require addiction to be part of 
nursing curricula. 88 Addiction, including the 
topic of smoking cessation, may be included as 
topics on the licensing exams for registered and 
practical/vocational nurses. 89 The American 
Academy of Nursing recently published new 
core clinical competencies in mental health that 
should be expected of all RNs. They include 
knowledge about the disease of addiction, 
addiction treatment, the pharmacology of 
commonly-misused illicit and prescription 
drugs, comprehensive screening, motivational 
interviewing, patient outcome evaluation, 
comprehension of research literature and the 
adoption of evidence-based practices. 90 

In most states, advanced practice nurses (APN) 
must earn a master's degree and are authorized 
to prescribe both non-controlled and controlled 
substances; 91 however, few states explicitly 
include addiction-related content in their training 
requirements. 

The International Nurses Society on Addictions 
(IntNSA) offers an optional certificate in 
addiction nursing; to qualify, candidates must 



1 In CA, RNs must complete studies in alcohol and 
other drug addiction; however, the exact amount is 
not specified. In IL, programs in practical nursing 
must include a course in pharmacology which must 
include topics on substance use and addiction. IN 
and RI require some addiction education and NJ 
requires six contact hours in pharmacology related to 
controlled substances including the prevention and 
management of addiction involving these substances. 



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have 200 hours (one year) of addiction-specific 
experience as an RN and pass an examination. 92 

Mental Health Professionals 

As is true of medical professionals, the licensing 
of mental health professionals is regulated by the 
states, which defer to national accreditation 
organizations and professional boards. 

Psychologists. Licensed clinical and counseling 
psychologists must obtain a doctorate degree 
from a PhD or PsyD program at an accredited or 
government-chartered institution acceptable to 
the American Psychological Association (APA) 
licensing board. 93 They also must pass a 
national licensing examination, the Examination 
for Professional Practice in Psychology, 
administered by the Association of State and 
Provincial Psychology Boards. 94 Vermont and 
West Virginia offer a psychologist license at the 
master's level* 

In the course of their practice—whether in the 
mental health care system, the general health 
care system, the correctional system, schools 
and universities or specialty addiction treatment 
programs— clinical and counseling psychologists 
encounter many patients who engage in risky 
substance use or have addiction. Psychologists 
often hold administrative and supervisory 
positions in specialty addiction treatment 
programs and other health and social welfare 
systems with large numbers of substance- 
involved individuals. 95 Yet CASA Columbia's 
review found that in most states, addiction is not 
a required element of psychologists' training. ' 

In the national licensing exam for 
psychologists, addiction-related content may 
appear as part of the required knowledge base in 



A number of states also license temporary or 
renewable psychological associate licenses for 
master's level supervised practitioners. 

* CA requires all licensed psychologists to have some 
level of addiction-related education; applicants must 
complete at least a semester course in addiction 
detection and treatment. 

* The Examination for Professional Practice in 
Psychology, administered by the Association of State 
and Provincial Psychology Boards (ASPPB). 



several content areas, including "biological 
bases of behavior" and "assessment and 
diagnosis. " § 96 

The APA had offered an optional certificate 
related to substance use and addiction which, 
although recognized by some state agencies, 
was not required for a psychologist to treat 
patients with addiction; the only requirement for 
this certification was experience in treating 
addiction as a licensed psychologist for at least 
one year. 97 As of January 1, 201 1, the APA 
Practice Organization (APAPO) discontinued 
accepting new applications for the Certificate of 
Proficiency in the Treatment of Alcohol and 
Other Psychoactive Substance Use Disorders but 
continues to support the credential for 
previously-certified psychologists who maintain 
their certification by engaging in appropriate 
continuing education. The decision to 
discontinue the certification program for new 
applicants was based in part on insufficient 
interest in obtaining the credential by licensed 

98 

psychologists. 

Mental Health Counselors/Therapists. All 

states license mental health counselors 99 and, 
with the exception of the "professional 
counselor" license in Illinois, ft all states require 
at least a master's degree in counseling or a 
related field. 

The National Board for Certified Counselors 
(NBCC) offers certification to become a 
National Certified Counselor (NCC); in 
addition, three optional national specialty 
certifications are offered on the graduate level to 
become a school counselor, clinical mental 



§ Although these content areas constitute 40 percent 
of the test, the exact proportion of substance 
use/addiction content is not specified. 

There are a number of different ways that state 
agencies have recognized the certificate. Most states 
use it as one way for psychologists to be listed as 
registered addiction treatment providers or as one 
way to qualify them as clinical supervisors. The 
significance of these categories depends on the state's 
regulations. 

^ IL requires only a bachelor's degree. IL also has a 
"clinical professional counselor" license which 
requires a master's degree. 



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health counselor and master addictions 
counselor.* 100 The National Counselor 
Examination for Licensure and Certification 
(NCE), administered by NBCC, is required for 
those seeking certification. The NCE exam does 
not appear to contain substance use/addiction- 
related content; 101 however, the specialty 
certification exam administered by the NBCC 
for the master addictions counselor exam 
focuses on addiction. 102 The master addictions 
counselor certification requires (1) a minimum 
of 12 semester hours of graduate coursework in 
addiction content or 500 continuing education 
hours in addiction content; (2) three years of 
supervised experience as an addiction counselor 
at a minimum of 20 hours per week (two of the 
three years must have been completed after 
obtaining the master's degree in counseling); 
and (3) a passing score on the examination for 
master addictions counselor. 103 National 
certification is voluntary; however, in some 
states, counselors are exempt from taking a state 
certification exam if they pass the national 

104 

exam. 

Professional counselors are trained to provide 
treatment for mental, emotional and behavioral 
disorders and tend to encounter in their practice 
individuals who engage in risky substance use or 
have addiction. 105 Although risky substance use 
and addiction may be addressed under broad 
course content areas, CASA Columbia's review 
found few explicit state licensing requirements 
that mandate a specific number of addiction- 
related education hours in their curriculum 
guidelines. 1 

The Council for Accreditation of Counseling 
and Related Educational Programs (CACREP), 
which accredits master's programs in numerous 
counseling specialties, requires all programs to 
provide students with an understanding of 
"theories and etiology of addictions and 
addictive behaviors, including strategies for 



The NCC is a pre- or co-requisite for the specialty 
credentials. 

1 More frequently, states mention substance use and 
addiction as topics that may be addressed under 
content areas such as human growth and development 
or that may be taken as electives or continuing 
education courses. 



prevention, intervention and treatment." The 
CACREP specifically includes additional 
substance-related content in the curricular 
requirements for clinical mental health 
counseling; marriage, couple and family 
counseling; school counseling; and student 
affairs and college counseling programs. 106 
Surveys of these programs reveal, however, that 
the majority of CACREP-accredited master's 
programs in counseling offer elective courses 
but do not require substance use/addiction- 
related course work. When asked to identify 
which courses teach addiction-related content, 
CACREP programs typically cite supervised 
clinical settings (practicums and internships), 
where students encounter patients who engage in 
risky substance use or have addiction, rather 
than classroom-based courses. Most counseling 
degree programs do not provide any addiction 
education prior to the clinical experience. 107 

Marriage and Family Therapists. Marriage and 
family therapists either must have a master's 
degree, a doctoral degree or three to four years 
of post-graduate clinical training for licensure. 108 
According to CASA Columbia's review, few 
states have explicit addiction-related education 
requirements (such as minimum number of 
hours of addiction content); most states that 
mention addiction include it as an optional or 
suggested topic or as a topic eligible for 
continuing education credit. The national 
licensing exam in Marital and Family Therapy is 
administered by the Association of Marital and 
Family Therapy Regulatory Boards (AMFTRB). 
In drafting the Examination in Marital and 
Family Therapy, the Examination Advisory 
Committee draws from a list of the 56 
knowledge areas required for entry- level 
practice in marital and family therapy, which 
includes two areas related to substance use and 
addiction. 1 109 

Social Workers. Some social workers function 
as mental health professionals, providing 
counseling services. Social workers must earn, 



1 The substance-related areas in the AMFTRB are 
"effect of substance abuse and dependence on 
individual and family functioning" and "addiction 
treatment modalities." 



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at a minimum, a bachelor's degree in social work 
(BSW); however, a master's degree in social 
work (MSW) often is required for positions in 
health care settings or to provide clinical 
services. 110 

The Association of Social Work Boards 
(ASWB), which regulates the profession, 
administers four separate examinations: the 
bachelor's exam, master's exam, advanced 
generalist exam and clinical exam. Each state 
determines the examination required for 
licensure. 

More than 25 percent of patients whom social 
workers come into contact with either have a 
primary or secondary diagnosis of addiction. 111 
While addiction-related content is mentioned 
explicitly as a topic area that may be included in 
the bachelor- and clinical-level licensing 
examinations, 112 CASA Columbia's review 
identified just two states— California and Alaska- 
-that require social workers to complete 
coursework in addiction. ' 113 

The National Association of Social Workers 
offers an optional Certified Clinical Alcohol, 
Tobacco, and Other Drugs Social Worker (C- 
CATODSW) certification for master's level 
social workers with 180 hours of addiction- 
related education and two years of paid, 
supervised post-graduate work experience in 
both clinical social work and addiction 
counseling. * 114 



In general, the bachelor's exam is designed for 
those with a BSW and no post-degree experience; the 
master's exam is for those with an MSW and no post- 
degree experience; the advanced generalist exam is 
for those with an MSW and at least two years of post- 
degree experience in non-clinical settings; and the 
clinical exam is for those with an MSW and at least 
two years of post-degree experience in direct clinical 
practice settings. 

* In CA, the applicant must obtain at least 15 hours of 
addiction-related training. In AK, licensed social 
workers must complete 45 hours of continuing 
education, including six hours of addiction-related 
education during their bi-annual license renewal 
cycle. 

* Nationwide data on the number of practicing social 
workers with this certification are not available. 



Acupuncturists 

Acupuncture sometimes is used as an 
alternative/complementary treatment for 
addiction. Estimates are that several hundred 
addiction treatment clinics in the U.S. and 
Europe offer auricular acupuncture, a procedure 
that targets chronic diseases, including addiction 
through needle therapy of the ear (typically used 
to treat cocaine addiction). 115 Despite its 
widespread use, there is very little research 
supporting the efficacy of auricular acupuncture 
for the treatment of addiction. 116 

CASA Columbia's review found that most states 
require individuals who practice acupuncture to 
be licensed. Licensing requirements include 
earning a degree from an accredited acupuncture 
school and, except in four states, professional 
certification or examination by the National 
Certification Commission for Acupuncture and 
Oriental Medicine (NCCAOM). In Alabama 
and North Dakota, which do not have licensure 
requirements for acupuncturists, only 
physicians, osteopaths or chiropractors may 
practice acupuncture as permitted by their scope 
of practice or via specialty certification. 5 117 

CASA Columbia's review identified several 
states that require specialized training and 
certification to practice auricular acupuncture. 
In California, acupuncture training programs are 
required to teach both auricular acupuncture and 
principles of public health, including treatment 
of addiction. 118 Acupuncturists certified through 
NCCAOM for Acupuncture and Oriental 
Medicine are not required explicitly to have 
addiction-related training, although substance- 
related knowledge is in the exam content for the 
"diplomate in acupuncture" certification. 119 The 
National Acupuncture Detoxification 
Association (NAD A) 120 certifies Acupuncture 



s In KS, acupuncturists may practice under the 
supervision of a medical doctor, osteopath or 
chiropractor. In OK, medical doctors may practice 
acupuncture. In SD, chiropractors may practice 
acupuncture. WY has no laws or regulations 
permitting or prohibiting acupuncture practice. 



-185- 



Detoxification Specialists (ADS) and has its 
own set of training guidelines.* 121 

Addiction Counselors 

Addiction counselors, also known as Substance 
Abuse Counselors (SACs), Credentialed 
Alcoholism and Substance Abuse Counselors 
(CASACs) or Alcohol and Drug Counselors 
(ADCs), make up the largest share of full-time 
addiction treatment provider staff in facilities 
providing addiction treatment in the United 
States. 122 

Addiction counselors can be licensed, certified 
or both. 123 CASA Columbia's review found that 
37 states require addiction counselors either to 
be licensed or certified, although even these 
states may provide important exemptions. ' 

The review also found that to become a licensed 
addiction counselor in a given state, generally 
one must meet the state's minimum education 
and training requirements and pass a designated 
exam. There is no one national licensing exam 
used to measure competencies. 124 The state 
education qualifications for licensure vary 
greatly/ 125 According to CASA Columbia's 
review, more than half of states that offer 
licensing require a master's degree for the 



The NADA training guidelines include 30 hours of 
didactic classroom training (e.g., history of the 
profession; the NADA protocol which defines the 
five points where needles are to be applied; 
techniques; clean needle; integration with larger 
treatment program; ethics) and 40 hours of hands-on 
clinical work (content not specified), supervised by a 
licensed acupuncturist. 

' Such as supervised students engaged in practicum, 
licensed health care professionals (e.g., MDs, RNs, 
psychologists) working within their scope of 
profession, religious leaders working within the 
scope of their ministerial duties, government 
employees working within the scope of their 
employment, and short-term services provided by 
non-residents who are certified in another state. 
* There are several tiers of addiction counselors— such 
as Certified Alcohol and Drug Abuse Counselor 
(CADAC) or Substance Abuse Counselor (SAC)- 
each with its own proficiency requirements (based on 
education and experience). The highest level usually 
requires a master's or doctorate degree. 



highest level of licensure, although several states 
offer the highest level of licensure to individuals 
who only have a bachelor, associate or high 
school degree. A 1998 survey similarly found 
that 56 percent of licensed addiction counselors 
have at least a master's degree. 126 

A variety of state boards and non-governmental 
organizations are designated with responsibility 
for certifying addiction counselors. 127 Similar to 
the licensure process, certification recognizes 
that addiction counselors have met what the 
organization deems to be minimum standards of 
education and clinical experience. 128 In some 
states addiction counselors must be certified 
while in other states certification is voluntary. 129 
Some state certification boards defer to 
standards established by professional 
membership or credentialing organizations, such 
as the International Certification and Reciprocity 
Consortium (IC&RC) or NAADAC, the 
Association for Addiction Professionals, 5 130 
which do not stipulate a particular required 
degree for the entry level certification. 131 

The IC&RC establishes minimum education and 
training standards for the credentialing of 
addiction counselors— each state certification 
board that is a member of the IC&RC 
consortium either may follow the minimum 
standards or impose higher standards. 132 The 
focus of the minimum requirements for the 
IC&RC Alcohol and Drug Counselor (ADC) 
certification is more on clinical work experience 
than on classroom-based education: 
requirements include 270 hours of education in 
the eight domains of addiction counseling, 300 
hours of supervised practical experience in the 
eight domains, 6,000 hours of supervised 



s The National Association for Alcoholism and Drug 
Abuse Counselors (NAADAC) changed its name in 
2001 to NAADAC, the Association for Addiction 
Professionals to reflect the increasing number of 
addiction professionals who address forms of 
addiction involving behaviors other than substance 
use, such as gambling. 

The eight domains include: clinical evaluation; 
treatment planning; referral; service coordination; 
counseling; client, family and community education; 
documentation; and professional and ethical 
responsibilities. 



-186- 



professional work experience specific to the 
eight domains and successful completion of a 

1 33 

written examination. 

NAADAC, the Association for Addiction 
Professionals offers three levels of certification 
for addiction professionals based on experience 
and education. 134 Like the IC&RC requirements 
for the National Certified Addiction Counselor, 
Level I (NCAC I), the focus primarily is on 
clinical work experience rather than on 
classroom-based education. Requirements 
include: (1) a current state certificate or license 
as an addiction counselor; (2) 270 contact hours 
of addiction counseling training; (3) three years 
of full-time work experience or 6,000 hours of 
supervised experience as an addiction counselor; 
and (4) successful completion of a written 
examination. 

These certification requirements reflect a great 
reliance on apprenticeships as the training model 
for addiction counselors. 136 

CASA Columbia's state-by-state analysis of 
regulations and statutes found that 14 states do 
not require addiction counselors in all settings to 
be licensed or certified. Six states do not 
mandate any degree to become credentialed as 
an addiction counselor; 1 in 14 states, an 
individual may become licensed or certified as 
an addiction counselor with the minimum 
education requirement of a high school diploma 
or a GED; an associate's degree is required in 10 



In AR, counselors who are not licensed or certified 
must register with the state; CT, FL and NY do not 
require supervised staff and MA does not require 
staff in licensed facilities to be licensed or certified; 
ID, MS, OR, and SD require licensing or certification 
of counselors only in certain facilities (e.g., licensed 
facilities or those that receive public funds); HI 
insurance law requires clinical licensure and 
certification to qualify for reimbursement; in MO, 
staff who are not licensed or certified have a limited 
scope of practice; in WV, only counselors in opioid 
treatment facilities must be certified or licensed; and 
AK and NH do not appear to require counselors to be 
licensed or certified. 

' In states where no degree is required, certification 
requirements typically include 270 hours of 
education in addiction counseling. 



states, a bachelor's degree is required in six 
states and a master's degree is the minimum 
requirement in only one state.* 

CASA Columbia's survey of New York State 
addiction treatment staff providers found that 
35.0 percent had a graduate degree, 27.7 percent 
had a bachelor's degree, 29.9 percent had some 
college or an associate's degree and 6.6 percent 
had only a high school or GED degree. 137 

In spite of the limited education and training 
requirements and the apprenticeship model of 
training, the essential practice dimensions of 
addiction counseling are defined as including 
clinical evaluation; treatment planning; referral; 
service coordination; and individual, group, 
family and couples counseling 138 — practices that 
would seem to require far more extensive and 
structured clinical training than the field of 
addiction counseling requires. 

Licensure, Certification and 
Accreditation Requirements for 
Addiction Treatment Programs and 
Facilities 

Just as licensing and certification requirements 
are insufficient to assure that those providing 
addiction treatment have the knowledge and 
skills to do so, government and professional 
oversight of addiction treatment facilities and 
programs is insufficient to insure that patients 
receive clinically-indicated, quality care. 

Regulatory oversight of health care facilities 
may include state licensure, certification^ and/or 
accreditation by a national accrediting 
organization. Licensing and certification 
standards may include: 



1 CASA Columbia reviewed the minimum education 
requirements for certification/ licensure in each state. 
In many states, counselors who meet only the 
minimum education requirements must be 
supervised. 

§ In the case of opioid maintenance therapy. 



-187- 



• Professional staffing requirements to assure 
that clinical staff are adequately qualified to 
implement evidence-based practices; 

• Requirements related to services to be 
delivered; or 

• Requirements that treatment services 
actually help patients achieve desired 
outcomes of improved health and 
functioning. 139 

Like health care facilities, addiction treatment 
programs are subject to state licensing 
requirements; however, for addiction treatment 
programs, these requirements typically are set by 
state agencies separately charged with authority 
to oversee addiction services rather than by the 
agencies responsible for regulating health care 
facilities. 140 CASA Columbia's review of 
licensing and certification requirements for 
addiction treatment facilities and programs ' 
found that the nature and extent of these 
regulations vary significantly among states and 
that certain addiction treatment programs (e.g., 
many state-run and religious programs) are 
exempt entirely from state regulation. In 
facilities that are subject to state regulation, the 
staffing requirements do not consistently 
mandate the involvement of professionals who 
are capable of providing a full range of effective 
interventions (including pharmaceutical and 
psychosocial therapies), services rarely are 
required to reflect best practices and quality 



Including (1) organizations or facilities that provide 
non-hospital based residential or outpatient addiction 
treatment, or opioid replacement therapy (e.g., 
methadone maintenance clinics) and (2) hospital- 
based inpatient and outpatient addiction treatment 
programs. 

1 This entailed online reviews and analyses of 
publicly available documents related to federal and 
state laws and regulations (in all 50 states and the 
District of Columbia), including the use of the 
Lexis/Nexis database to supplement information 
related to state laws and regulations available on the 
Internet. Because licensing and certification 
requirements are found in a wide variety of laws and 
regulations and can change on a state by state basis, 
findings from this review cannot be guaranteed to be 
complete and current. 



assurance requirements seldom stipulate that 
patient outcome data be collected, analyzed or 
made available to the public. For no other 
health condition are such exemptions from 
routine governmental oversight considered 
acceptable practice. 

State Licensing Requirements 

Health care facilities such as hospitals and 
ambulatory care (outpatient) clinics are licensed 
by state departments of health, whereas the 
licensing authority for addiction treatment 
facilities and programs is distributed across a 
variety of governmental agencies and the 
content of statutes and regulations varies greatly 
by state. 141 

Most (81.9 percent) addiction treatment facilities 
and programs that voluntarily participate in a 
national survey of such providers 1 are licensed 
by the state agency responsible for addiction 
services (which varies from state to state): 41.4 
percent of facilities are licensed by the state 
department of health; 35.3 percent by the state 
mental health department; and 7. 1 percent by the 
hospital licensing authority. 5 142 

Despite the abundant evidence that addiction 
and mental health conditions co-occur at very 
high rates and are best addressed in an integrated 
manner, in some states, treatment facilities and 
programs cannot be dually licensed to provide 
both mental health and addiction treatment 

143 

services. 



1 The National Survey of Substance Abuse Treatment 
Services (N-SSATS) of the Substance Abuse and 
Mental Health Services Administration (SAMHSA) 
is a national survey of public and private addiction 
treatment programs and facilities in the United States, 
excluding treatment programs in jails and prisons. 
Participation is voluntary and the survey does not 
represent all treatment providers. 
§ These categories are not mutually exclusive. More 
than half (57.7 percent) of the addiction treatment 
facilities that participate in the survey are not 
licensed either by the state department of health or 
the hospital agency— the two departments responsible 
for licensing health care facilities. 



-188- 



A significant number of states exempt state 
agency-run programs (e.g., in the justice and 
welfare systems) from licensure. A national 
study of state-run treatment programs found that, 
excluding programs provided or operated by the 
state addiction treatment agencies, only about 
one-half of state agencies that operate treatment 
programs require the programs they operate to 
meet state licensure standards: 144 

• 38 states report that the department of 
corrections operates treatment programs, but 
only 1 8 of these require treatment programs 
operated by the corrections departments to 
meet state licensing standards.* 145 

• 1 3 states report that their juvenile justice 
system operates treatment programs, with 
only six states requiring these programs to 
adhere to state licensing standards. 146 

• Seven states identify their departments of 
child and family services as operating 
treatment programs, with only four requiring 
adherence to state licensing standards. 147 

• 18 states identified 2 1 other government 
agencies (e.g., departments of public 
welfare, mental health and criminal justice- 
related agencies other than the department of 
corrections) that operate treatment 
programs, but in only 1 1 states are these 
programs required to adhere to state 
licensing standards. 148 

CASA Columbia also found substantial 
inconsistencies in the regulation of faith-based 
programs that offer addiction-related services. 
While most states do not appear explicitly to 
address faith-based programs in their laws or 
regulations, some states explicitly exempt such 
programs from regulation^ 



Federal Regulatory Requirements 

The federal government does not regulate 
addiction treatment facilities or programs, with 
the exception of those that provide opioid 
maintenance therapy. 149 However, the federal 
government imposes certain conditions of 
participation on qualifying programs and 
facilities through federal health insurance 
programs, including Medicare, Medicaid, 
TRICARE for members of the active duty 
military and the veterans' health insurance 
program (CHAMP VA)— whether they are 
mainstream health care or addiction treatment 
providers. 150 Like state licensing laws, these 
provisions include requirements regarding 
staffing, services and quality assurance 
mechanisms. 

To be eligible to receive Medicare/Medicaid 
reimbursement, most treatments must be 
provided by or under the supervision of a 
physician. 151 State Medicaid programs have the 
option of covering addiction treatment under the 
Medicaid rehabilitation option, Medicaid clinic 
services, targeted case management and 
Medicaid managed care waiver programs. The 
rehabilitation option is the most flexible for 
treatment coverage in that it does not require 
services to be medically provided or 
supervised. 152 The Medicare/Medicaid 
Conditions of Participation impose extensive 
requirements on participating facilities including 
staffing, services and quality assurance 

• • t 153 

provisions. 



* A few states qualified the licensing requirement, 
saying that it only applied to certain types of facilities 
(e.g., one state noted that the requirement was for 
residential treatment facilities only). 
' Exemptions appear to apply to programs that solely 
are spiritual or religious in nature. 



1 In addition, under the Government Performance 
Results Act (GPRA) of 1993, federally-operated 
programs or those that receive federal funds for 
addiction treatment are required to meet certain 
reporting requirements. 



-189- 



All opioid maintenance therapy facilities are 
required by federal law to obtain certification 
from the U.S. Department of Health and Human 
Services' Substance Abuse and Mental Health 
Services Administration (SAMHSA) 
demonstrating compliance with established 
standards for opioid maintenance therapy 
programs. 154 It is a pre-requisite of certification 
that a program be accredited by an organization 
approved by SAMHSA.* 155 

Accreditation Requirements 

In lieu of or in addition to state licensure, 
addiction treatment facilities and programs may 
be accredited by a national accreditation 
organization. While adopting these standards 
largely is voluntary, 156 some states grant licenses 
to programs that have been accredited, 157 such 
that the program is deemed to have met the state 
licensure requirements because it has been 
approved by a national accrediting body.' 158 By 
granting "deemed status" licenses to accredited 
programs, the state essentially delegates to the 
accrediting body its responsibility for ensuring 
that the facility or program meets state licensure 
requirements. 159 Accreditation standards are 
more detailed than state licensing requirements 
and while some require facilities and programs 
to use evidence-based practices or to analyze 
patient outcomes, 160 not all do. Furthermore, 
accreditation standards do not require staff to be 
qualified to provide a full range of evidence- 
based treatment, and accreditation does not 
necessarily ensure that quality care is 
delivered. 161 

The accreditation process entails a review of the 
facility's or program's structure and operational 
practices and evaluation of the organization's 
clinical care processes and outcomes to confirm 
that they comply with standards set by the 



To be approved by SAMHSA to accredit opioid 
maintenance therapy programs, an accrediting 
organization must demonstrate how its accreditation 
process will ensure that programs meet the standards 
described in federal regulations. 
' Select examples of states that allow providers to 
have deemed status for state license or require 
accreditation for Medicaid include: AL, AK, AZ, AR, 
CT and DE. 



accrediting body. Accreditation generally is 
considered a higher standard of oversight than 
state licensing, in that it incorporates "ideal or 
optimum" standards rather than minimum 
standards, and focuses on continuous quality 
improvement. 163 

A 2007 study of the association between 
accreditation and nine indicators of quality care 
(categorized as staff-to-patient ratio, treatment 
comprehensiveness and treatment sufficiency) in 
566 outpatient addiction treatment programs 
found only several correlations between 
accreditation and quality of care measures. 164 
Another study that examined the adoption of 
evidence-based dosing practices in methadone 
maintenance programs found that voluntary 
accreditation was strongly related to adoption of 
these practices; however, after accreditation 
became mandatory in 2000, this relationship 
disappeared. The authors speculated that 
programs that voluntarily seek accreditation tend 
to be resource-rich (in funds, staff and training) 
and more motivated to improve their quality of 
care, and therefore more likely to adopt 
evidence-based practices. 165 

The five organizations that accredit addiction 
treatment programs and facilities in the United 
States are: 

• The Commission on Accreditation of 
Rehabilitation Facilities ( CARF). CARF is 
an independent, nonprofit organization that 
offers accreditation for addiction treatment 
programs and facilities and integrated 
addiction/mental health treatment programs 
and facilities; it is the largest accreditor of 
addiction treatment programs and 
facilities. 166 CARF accreditation is widely 
accepted by state licensing agencies toward 
the fulfillment of licensing requirements for 
addiction treatment programs and 
facilities. 167 

• The Joint Commission on Accreditation of 
Healthcare Organizations (Joint 
Commission). The Joint Commission is the 
largest accreditor of all health care services 
in the U.S. 168 and the second largest 
accreditor of addiction treatment programs 



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and facilities. 169 Joint Commission 
accreditation is widely accepted by state 
licensing agencies toward the fulfillment of 
licensing requirements for addiction 
treatment programs and facilities. 170 

• The Council on Accreditation (CO A). COA 
is an international accrediting organization. 
Originally known for accrediting family and 
children services agencies, COA currently 
accredits numerous services, including 
addiction treatment. 171 COA accreditation is 
accepted by fewer states (approximately 1 0) 
relative to accreditation by CARF or the 
Joint Commission. 172 

• The National Committee for Quality 
Assurance (NCQA). NCQA is a nonprofit 
health care quality improvement 
organization that accredits health care 
organizations. 173 As of 2005,* Florida and 
Michigan were the only states that accepted 
NCQA accreditation as fulfilling licensing 
requirements for addiction treatment 
programs and facilities. 174 

• The National Commission on Correctional 
Health Care (NCCHC). The NCCHC is the 
only organization authorized by the federal 
government to accredit opioid maintenance 
therapy programs that specialize in 
correctional settings. 175 

Of the 13,339 addiction treatment programs and 
facilities voluntarily responding to a national 
survey 



.t 



56.9 percent (7,595 facilities) are not 
accredited by CARF, the Joint Commission, 
COA or NCQA; 

21.8 percent (2,909 facilities) are accredited 
by CARF; 



19.2 percent (2,556 facilities) are accredited 
by the Joint Commission; 

5.0 percent (664 facilities) are accredited by 
COA; and 

2.8 percent (371 facilities) are accredited by 
NCQA. 



176 



Professional Staffing Requirements 

In licensing standards for medical facilities, 
physicians generally are responsible for patient 
care.* 177 In contrast, addiction treatment may be 
provided not only by people who lack medical 
training, but by individuals with no license and 
no graduate education or clinical training at 
all. 178 

State licensing laws, federal requirements and 
accreditation standards regarding which 
professionals may provide and supervise 
addiction treatment services in facilities and 
programs vary significantly. While some states 
require addiction treatment programs to have a 
medical director who is an M.D. on staff, others 
impose minimum education/training 
requirements on directors, supervisors and staff. 
Accreditation standards do not recognize 
addiction treatment generally as requiring 
medical care; rather, they only require physician 
oversight for certain services, deferring to states 
with regard to which professionals are qualified 
to provide addiction treatment. Similarly, 
federal requirements stipulate that some types of 
care must be provided under the supervision of a 
physician, while services such as "rehabilitation 
services" do not require supervision by a 
physician. 179 

State Staffing Requirements. In licensing 
regulations for addiction treatment facilities and 
programs, states typically specify: 



The most recent data available. More states may 
currently accept the accreditation. 
1 The National Survey of Substance Abuse Treatment 
Services (N-SSATS). Accreditation by the NCCHC 
was not measured in the survey. The categories are 
not mutually exclusive, as programs and facilities 
may have multiple accreditations. 



1 Dentists and other health professionals may be 
responsible for services they are qualified to perform 
or supervise. 



-191- 



• A wide range of "qualified providers" (e.g., 
addiction counselors, social workers, nurses) 
who may offer and/or supervise treatments- 
most of whom are not qualified to provide 
medical care or are not trained in addiction; 

• The total proportion of patient care that must 
be provided by "qualified providers"; and 

• The ratio of staff to patients. 180 

Although state licensing requirements allow an 
array of practitioners to provide addiction 
treatment, the licensing requirements for 
addiction treatment facilities and programs 
typically state that "medical services" must be 
provided or supervised by a physician; however, 
medical services are defined as detoxification, 
opioid replacement therapy or the assessment, 
diagnosis and treatment of co-occurring medical 
or mental health conditions, not as addiction 
treatment itself. 181 

According to CASA Columbia's review, 43 
states require non-hospital-based 1 outpatient and 
residential addiction treatment programs to 
employ (at least part time) a physician to serve 
either as medical director or on staff; however, 
this requirement applies primarily to programs 
that provide opioid maintenance therapy which, 
by federal regulation, must be supervised by a 
physician. 182 Few states require non-hospital- 
based programs that do not provide opioid 
maintenance therapy to have a physician serving 
as medical director or on staff; 1 states require 
residential treatment programs to have a 
physician either as a medical director or on staff 
and eight states require the same of outpatient 
treatment programs. Without a physician as 
medical director or on staff, addiction treatment 
programs cannot provide a full range of 
evidence-based treatment services including 



Qualified providers are those who, under state law, 
may provide addiction treatment. 
' See section on Licensing and Credentialing 
Requirements for Individuals who Provide Addiction 
Treatment, above. 

* Hospital licensing requirements require physician 
supervision of patient care; however, the majority of 
addiction services offered are not hospital based. 



pharmaceutical therapy and treatment of co- 
occurring health conditions. 

Consistent with these requirements, addiction 
treatment services typically are not required to 
be supervised by a physician, other than for the 
provision of narrowly-defined "medical 
services." While states may require that 
addiction services be overseen by a clinical or 
program director, that position is not required to 
be filled by a physician. 

Approximately two-thirds of states in CASA 
Columbia's review specify that residential 
treatment programs (3 1 states) and outpatient 
treatment programs (29 states) must have a 
program or clinical director. Among the 2 1 
states that specify the minimum educational/ 
training requirements for this position, few have 
particularly high standards: 

• Eight states require a minimum of a master's 
degree; 

• Six states require the director to be a 
licensed or certified addiction counselor; 

• Four states require a minimum number of 
years of experience; 5 

• One state requires a bachelor's degree; 

• One state requires an associate's degree; and 

• One state simply requires the person to 
demonstrate competence to perform certain 
services. 

A national survey of treatment professionals 
conducted in 1998 found that 60.6 percent of 
individuals who were responsible for 
supervising clinical services in addiction 
treatment facilities had graduate degrees and 
77.5 percent of these supervisors were certified 
or licensed as addiction/mental health 
professionals. Among facility directors, 64.0 
had a graduate degree and 68.9 percent were 



s AZ additionally specifies that the individual must 
have a high school diploma or GED. 



-192- 



certified or licensed as addiction/mental health 
professionals. 183 

CAS A Columbia's survey of directors* of 
addiction treatment programs in New York State 
found that 67.5 percent had a graduate degree, 
16.9 percent had a bachelor's degree, 14.5 
percent had some college or an associate's 
degree and 1 .2 percent had only a high school or 
GED degree. 184 

Although state licensing laws sometimes dictate 
that clinical supervisors, such as program or 
medical directors, have special training 
(including certification) or experience in 
addiction treatment, 185 they generally allow 
facilities more flexibility to determine the 
necessary qualifications, including level of 
experience, education or training, as well as the 
composition of other clinical staff 186 

Federal Staffing Requirements. In states that 
provide addiction treatment using Medicaid 
funding, hospital and clinic services must be 
provided under the direction of a physician, 187 
but if states choose to provide services under the 
optional benefits category of rehabilitative care, 
they are exempt from this requirement. 188 If 
services are required to be provided under the 
direction of a physician, the facility physician is 
not required to be on staff full time, but must be 
present for sufficient time to provide medical 
direction, care and consultation in accordance 
with accepted principles of medical practice. 
The facility and the staff providing care also are 
required to hold appropriate state licenses, 
certifications or registrations. 189 

The federal regulations for opioid maintenance 
therapy programs specify that each program 
must employ a medical director and that all 
providers, including addiction counselors, 
comply with the credentialing requirements of 
their respective profession. 190 



Some of the program directors also may have 
served as clinical supervisors, but the survey did not 
distinguish between the two roles. 



Accreditation Requirements Regarding 
Staffing. 1 CARF standards require that 
programs that offer detoxification, inpatient 
care, partial hospitalization, residential treatment 
serving "persons with medical needs" or opioid 
maintenance therapy have a medical director 
who is a physician. Organizations that seek 
elective accreditation for assertive community 
treatment (ACT)* services must have a physician 
on staff. Other services do not require physician 
supervision. 191 

While CARF requires staff to be licensed or 
certified by a credentialing body that uses a 
competency-based process, 5 it leaves the 
determination of which practitioners are 
qualified to provide addiction treatment to state 
laws and professional associations, thus 
allowing for great variation in education and 

192 

training requirements. 

The Joint Commission allows programs to 
define the qualifications required for staff to 
perform their job and requires staff who provide 
care to be licensed, certified or registered "in 
accordance with the law." Only opioid 
maintenance therapy programs must have a 
physician on staff; this person must have 
experience in addiction medicine, including 
medication-assisted treatment. 193 

Treatment Service Requirements 

Licensed health care facilities must deliver care 
that meets standards of medical practice; state 
regulations tend to defer to health care 
providers— for whom there are well-delineated 
standards of education and training in health 
care practice— to determine appropriate medical 
practice (e.g., which services to provide and how 
to provide them). 194 In contrast, those who 
provide addiction treatment often have minimal 



' CASA Columbia reviewed the standards of the two 
largest accreditors of addiction treatment programs— 
CARF and the Joint Commission. 
* As described in Chapter VI, ACT is a treatment 
approach for patients with co-occurring addiction and 
mental health conditions. 

§ Focused on the ability to demonstrate adequate 
skills, knowledge and capacity to perform a specific 
set of job functions. 



-193- 



education or training in addiction science, and 
there are no accepted standards of practice that 
apply across facilities and programs. 195 

While most states regulate addiction treatment 
services, they treat these services as completely 
separate and distinct from medical care,* 196 and 
state regulations regarding addiction treatment 
service requirements vary considerably and tend 
to be vague. Accreditors specify required 
services in greater detail than state licensing 
regulations, as do the federal requirements for 
facilities providing opioid maintenance therapy. 

State Services Requirements. According to 
CASA Columbia's review, the majority of states 
regulate the content of addiction services by 
requiring adherence to specific guidelines, but 
the extent of the regulation varies considerably. 1 
In addition to listing the types of required 
services, the frequency and timing of services 
are specified in some cases; for example, 
patients receiving detoxification must receive a 
psychosocial assessment within 72 hours of 
admission 197 or patients in intensive outpatient 
programs must receive individual or group 
therapy for a minimum of six hours over at least 
two days a week. 198 

More than 30 states require addiction treatment 
programs and facilities to utilize the American 
Society of Addiction Medicine (ASAM) patient 
placement criteria, which guide providers in 
matching patient needs to specific treatment 
services and determining the appropriate level of 
care for patients. 199 

State regulations related to addiction treatment 
services tend to specify the categories of 
services that addiction facilities and programs 
must offer— such as individual, family and group 



Except for opioid maintenance therapy and some 
detoxification services, which are considered medical 
care and must be supervised by a physician. 
' Regulations were considered to provide detailed 
guidelines if they included, for example, specific 
pharmaceutical dosing schedules or specific 
assessment criteria (e.g., including onset/duration of 
problems, previous interventions/outcomes, health 
history/current medical care needs and daily living 
skills). 



counseling; alcohol and other drug education; 
activity therapy and social services 200 ~but are 
not particularly specific in requiring that the 
services follow evidence-based practices. A 
survey conducted in 2006 found that three 
states— Oregon, North Carolina and Alaska- 
have enacted legislation that mandate or 
encourage the use of evidence-based practices in 
addiction treatment programs; only Oregon 
mandates programs to implement evidence- 
based practices under penalty of fiscal 
sanctions. 201 However, the reach of the Oregon 
law is limited to programs and facilities that are 
funded by the state. 1 202 

Federal Services Requirements. The federal 
regulations for opioid maintenance therapy 
programs include specific admission criteria, 
services and procedures for patient care. 
Admission is limited to patients who meet 
clinical diagnostic criteria for opioid 
dependence 1 * and the person must currently have 
addiction and must have become addicted within 
one year before treatment admission. A 
physician must perform a full medical 
examination before admission. Opioid 
maintenance therapy programs must provide 
medical care, addiction counseling, vocational 
and educational services and other assessment 
and treatment services. The regulations stipulate 
that random testing for addictive drugs must be 
performed on all patients periodically; ' ' that 
treatment medication dosing must be calculated 
by a physician familiar with the "most up-to- 
date" labeling; and that for patients receiving 



1 The Department of Corrections, the Oregon Youth 
Authority, the State Commission on Children and 
Families and the part of the Oregon Health Authority 
that deals with mental health and addiction issues. 
§ Determined using accepted clinical criteria, such as 
those in the DSM-IV. 

** The one -year requirement may be waived for 
persons released from penal institutions (within six 
months after release), pregnant women (a program 
physician must certify pregnancy) or previously- 
treated patients (up to two years after discharge). 
tt All patients are to be drug tested initially and then 
eight times per year for patients in maintenance 
treatment and monthly for persons receiving long- 
term detoxification treatment. 



-194- 



methadone, the initial dose cannot exceed 30 
milligrams. 203 

Accreditation Service Requirements. 

Accreditation organizations delineate detailed 
specifications related to addiction services 
provided by facilities and programs. 

CARF requires that addiction services be 
evidence based, explicitly stating that care 
should incorporate "current research, evidence- 
based practice, peer-reviewed scientific and 
health publications, clinical practice guidelines 
and/or expert professional consensus." The 
facility must have written policies regarding 
service delivery including screening, referrals, 
medication use and control, discharge and 
follow up. 204 CARF sets forth procedural 
requirements for the above services, as well as 
orientation, assessment and the development of 
"person-centered plans" for treatment. ' CARF 
offers accreditation standards for each of the 
"core program areas" that programs and 
facilities may elect to have accredited, such as 
assertive community treatment (ACT), 
community integration, 1 detoxification, day 
treatment, drug court treatment, partial 
hospitalization and inpatient services. Standards 
for the core program areas are very detailed and 
cover which services must be provided, by 
whom and how often. § 205 



The process of physically controlling, transporting, 
storing and disposing of medications, including those 
that are self-administered by patients. 
' Treatment plans developed with the input of 
patients regarding their goals, needs, strengths, 
abilities, preferences, desired outcomes and cultural 
background. 

* A form of treatment that provides opportunities for 
community participation as a means of optimizing 
personal, social and vocational competency in order 
to live successfully in a community. 
§ For example, day treatment must be provided at 
least three hours a day, four days a week; must 
include three interventions from a designated list of 
interventions (e.g., family therapy, group counseling, 
individual psychotherapy, occupational therapy, 
alcohol and other education) plus two additional 
activities (nutritional/fitness/leisure/social); the 
program must be directed by a qualified behavioral 
health practitioner (a person certified, licensed, 
registered or credentialed by a governmental entity or 



The Joint Commission requires facilities to have 
written procedures for eligibility for admission 
and for most services. The standards for 
addiction treatment programs include procedural 
requirements governing essential services such 
as screening and assessments; medical 
history/physical examinations; screening for 
physical pain, nutritional status and signs of 
trauma/abuse/neglect/exploitation; special 
provisions for services provided to vulnerable 
populations (children, individuals with 
intellectual/developmental disabilities); care that 
reflects patients' needs, preferences and goals; 
coordination of care; necessary referrals; 
primary physical care; and discharge/transfer 
that assures continuity of care. 206 The standards 
do not specify what kind of psychosocial or 
pharmaceutical services should be provided, 
leaving much room for variability in the quality 
of patient care. 

Because opioid maintenance therapy is 
considered "medical care," Joint Commission 
standards for opioid maintenance therapy 
programs are more numerous and detailed. For 
example, such programs must address relapse 
prevention in discharge planning; use DSM-IV 
or other accepted clinical criteria to diagnose 
addiction; perform an initial toxicology test and 
a comprehensive screening of patients' medical 
conditions; document current chronic or acute 
medical conditions; provide hepatitis A and B 
immunizations; manage current misuse of other 
drugs that are not the primary focus of 
treatment; and include smoking cessation as an 
integral component of care. 207 

Quality Assurance Requirements 

Quality assurance requirements can be imposed 
by state and federal governments, by accreditors 
or by payers. Such requirements focus on 
assuring specific organizational structures, 



a professional association as meeting the 
requirements necessary to provide mental health or 
alcohol and other drug services); screening and 
assessments must be provided; and when psychiatric 
services are necessary, a psychiatrist must be 
available 24-hours a day. 



-195- 



processes and outcomes as ways of assuring 
quality. 208 

Accreditation of health care facilities tends to 
focus on structural measures (e.g., physical plant 
adequacy, nursing ratios, certification of 
providers, availability of certain services). 
While patient outcomes (e.g., survival, function, 
quality of life) are in many ways the most 
important variables, they are difficult to collect 
and analyze. Patient outcomes may be affected 
by factors independent of the quality of a 
specific health care service delivered, including 
co-occurring conditions, patient compliance and 
lifestyle. Outcome data also are subjective and 
vary according to the setting and the particular 
instruments used to measure them. Given these 
barriers, quality assurance efforts tend to focus 
on the process of care, which examines the 
frequency with which interventions known to 
correlate with positive outcomes are 
performed. 209 

State Quality Assurance Requirements. State 
quality assurance requirements for addiction 
treatment programs and facilities are highly 
variable and focus mainly on process. For 
example, a program that is run efficiently and 
maintains good records would be considered a 
quality program regardless of patient outcomes. 

CASA Columbia's state-by-state analysis of 
regulations and statutes found that 45 states have 
some type of quality assurance requirements for 
addiction treatment facilities and programs, 
although this may take the form of simply 
requiring the establishment of a quality 
improvement plan. Fewer than half of these 
states (2 1 states) have explicit requirements that 
patient outcome data be collected but, even for 
those that do, the types of data required rarely 
are specified. Four of the states that require the 
collection of patient outcome data have 
explicitly-defined categories of such data, but 
these categories focus primarily on reductions in 
specific types of substance use or its 
consequences-such as reduction or elimination 
of the use of illicit drugs, reduction or 
elimination of associated criminal activities or 
improvement of quality of life. The absence of 
other indicators linked to improved health and 



function or effective disease management is 
noticeably absent. 

CASA Columbia's review found little evidence 
that states impose sanctions on facilities that fail 
to meet the outcome reporting requirements and, 
for those that do, the penalties are minor (e.g., a 
$100 fine). 

Federal Quality Assurance Requirements. 

Federal quality assurance requirements vary by 
program. Federal Medicare/Medicaid conditions 
of participation address quality assurance issues 
by requiring utilization review committees to 
assure compliance with written procedures for 
evaluating admissions, continued care and 
discharges; linking treatment plans to 
established goals; clinical record keeping; and 
requiring that the group of professionals within 
the program or facility that develops patient care 
policies review and act upon recommendations 
from the utilization review committee. 210 

The federal regulations for opioid maintenance 
therapy programs require continual quality 
assurance measures which must include ongoing 
assessment of patient outcomes (not specified) 
and annual review of program policies and 
procedures. 211 

All federal agencies that operate programs or 
provide funds related to addiction treatment are 
required to report on the performance of those 
programs in accordance with the Government 
Performance Results Act (GPRA) of 1993. In 
order to fulfill their requirements under the Act, 
each federal agency must develop a strategic 
plan (including annual performance targets) 
covering each of their programs, conduct 
evaluations to assess how well a program is 
working and why particular outcomes have (or 
have not) been achieved and produce program 
performance reports based on analyses of 
program effectiveness. 212 

SAMHSA is the leading federal agency that 
funds addiction treatment; it administers the 
Substance Abuse Prevention and Treatment 
Block Grant (SAPTBG), a federal grant that 
funds state prevention, treatment, recovery 



-196- 



supports and other services. SAPTBG is a 
major source of funding for state-run or state- 
funded treatment programs. 214 SAMHSA's 
performance targets and outcome measures for 
this program include required data collection 
and reporting on the number of admissions to 
treatment programs receiving public funding and 
on outcomes, including abstinence^ 
employment, school enrollment, justice system 
involvement and housing. 215 

Accreditation Requirements for Quality 
Assurance. CARF requires addiction treatment 
facilities and programs to conduct a records 
review to assess the quality and appropriateness 
of services provided, as well as a review of the 
patterns of service utilization. Programs must 
analyze patient outcomes— including abstinence; 
reduction in relapse, criminal activity and 
hospitalizations; improved psychological 
function; housing situation; employment status— 
to determine the effectiveness of services. 216 

Joint Commission standards for addiction 
treatment facilities and programs focus more on 
performance improvement measures by 
requiring programs to conduct data collection 
and data analysis and to identify any 
opportunities for improving performance (e.g., 
in reducing errors, incorporating patient goals or 
comparison with external quality measures). 
Only opioid maintenance therapy programs are 
required specifically to collect outcome data, 
which include measures of the use of illicit 
opioids, criminal involvement, health status, 
retention in treatment and abstinence. 217 



States that receive SAPTBG funds must, among 
other things: spend five percent of the funds on 
increasing treatment capacity for pregnant women 
and women with dependent children by establishing 
new programs or expanding the capacity of existing 
programs, improve the process for referring 
individuals to treatment facilities that can provide the 
most appropriate treatment modality, and make 
continuing education available to employees of 
funded facilities. 

' Measures of client abstinence reflect no past-month 
use of alcohol or other drugs at discharge. Discharge 
is defined as the date of last service. 



-198- 



Chapter X 

The Evidence-Practice Gap 



The prevention and reduction of the risky use of 
addictive substances and the treatment of 
addiction, in practice, bear little resemblance to 
the significant body of evidence-based practices 
that have been developed and tested;* indeed 
only a small fraction of individuals receive 
interventions or treatment consistent with 
scientific knowledge about what works. 1 

Providing quality care to identify and reduce 
risky use and diagnose, treat and manage 
addiction requires a critical shift to science- 
based interventions and treatment by medical 
professionals— both primary care providers and 
specialists. 

Significant barriers stand in the way of making 
this critical shift, including an addiction 
treatment workforce that is largely unqualified 
to implement evidence-based practices; a health 
professional that should be responsible for 
providing addiction screening, interventions, 
treatment and management but does not 
implement evidence-based addiction care 
practices; inadequate oversight and quality 
assurance of treatment providers and 
intervention practices; limited advances in the 
development of pharmaceutical treatments; and 
a lack of adequate insurance coverage. 

Recent efforts by government agencies and 
professional associations have begun to tackle 
these challenges to closing the evidence-practice 
gap, but are insufficient. 

Current Approaches to Risky 
Substance Use and Addiction Are 
Inconsistent with the Science and 
with Evidence-Based Care 

Unlike other public health problems and 
diseases that are met with qualified medical care 



See Chapters IV- VI. 



-199- 



and cutting-edge interventions, the reigning 
paradigm in the health community for 
addressing risky substance use and addiction is 
to fail to address the problem directly. Instead, 
risky users of addictive substances are in most 
cases sanctioned in terms of the consequences 
that result— such as accidents, crimes, domestic 
violence, child neglect or abuse-while effective 
interventions to reduce risky use rarely are 
provided. Those with addiction frequently are 
referred to support services, often provided by 
similarly-diagnosed peers who struggle with 
limited resources and no medical training, to 
assist them in abstaining from using addictive 
substances. While social support approaches are 
helpful and even lifesaving to many-and can be 
important supplements to medically-supervised, 
evidence-based interventions— they do not 
qualify as treatment for a medical disease. 

In short, the gap between the evidence regarding 
what works in interventions for risky substance 
use and in the treatment and management of 
addiction versus on-the-ground practice is wide, 
and nothing short of a significant overhaul in 
current approaches is required to bring practice 
in line with the evidence and with the standard 
of care for other public health and medical 
conditions. 

While a wide range of trained health 
professionals can screen for risky use of 
addictive substances and provide brief 
interventions, physicians should be essential 
providers of the full range of addiction treatment 
services. They should provide this care in 
collaboration with multiple medical specialties 
and sub-specialties and a multi-disciplinary team 
of health professionals, including physician 
assistants, nurses and nurse practitioners and 
graduate-level clinical mental health 
professionals (psychologists, social workers, 
counselors). 

Given the prevalence of addiction in society and 
the extensive evidence regarding how to 
identify, intervene and treat it, continued failure 
to do so signals widespread system failure in 
health care service delivery, financing, 
professional education and quality assurance. It 
also raises the question of whether the low levels 



of care that addiction patients usually do receive 
constitutes a form of medical malpractice. 

Patient Education, Screening, Brief 
Interventions and Treatment Referrals 

Despite the documented benefits of screening 
and early intervention practices, medical and 
other health professionals' considerable 
potential to influence patients' substance use 
decisions, and the long list of professional health 
organizations that endorse the use of such 
activities, most health professionals do not 
educate their patients about the dangers of risky 
substance use or the disease of addiction, screen 
for risky substance use, conduct brief 
interventions when indicated, treat the condition 
or refer their patients to specialty care if 
needed. 2 

Since the 1950s, screening has been considered 
an important element of general health care and 
as early as 1968, the World Health Organization 
(WHO) laid out the principles of early disease 
detection. 3 Based on those principles, risky 
substance use and signs of addiction are highly 
conducive to screening by general health 
practitioners: they are significant health 
problems with well-understood natural histories, 
there are non-invasive tests and easily-detected 
symptoms and early interventions result in 
favorable outcomes. 4 Unfortunately, there is a 
considerable gap between what current science 
suggests constitutes risky substance use and the 
thresholds set in some of the most common 
screening instruments for determining that an 
individual meets criteria for risky substance use 
and is in need of intervention (see Chapter IV). 

Medical and other health professionals are in 
ideal positions to educate patients, conduct 
screening and brief interventions and refer 
patients to treatment. The vast majority of 
adults (82.2 percent) and children (92.1 percent) 
had regular contact with a health professional in 
20 10. 5 There are many venues where health 
professionals can conduct patient education, 
screening and brief interventions with relative 
ease and most patients would be receptive to 



See Chapter IV. 



-200- 



these practices. 6 These include primary care 
medical offices, dental offices, pharmacies, 
school-based health clinics, mental health 
centers and clinics, emergency departments and 
trauma centers, hospitals or encounters with the 
justice system due to substance-involved 
crimes. 7 

Yet, there is no evidence to suggest that medical 
and other health professionals routinely avail 
themselves of these opportunities. 8 To the 
contrary, a 2000 CASA Columbia survey found 
that only 32.1 percent of physicians regularly do 
even one of the following: administer a health 
history form to patients at least annually with 
one or more substance use questions; administer 
a screening instrument to detect the risky use of 
one or more substances; discuss substance use 
with pregnant patients; or "almost always" ask 
patients about their substance use when they 
suspect a patient has a problem. 9 



The consequences of failure to identify risky use 
or detect signs of addiction can be life 
threatening. Mistaking symptoms of risky 
substance use for signs of other conditions may 
lead to a misdiagnosis or to prescribing 
medications that are unnecessary, produce 
dangerous drug interactions, compound an 
existing addiction problem* or create additional 
health risks. 1 1 



Thirty percent of patient respondents in CASA 
Columbia's 2000 survey of physicians and patients 
said their physician knew about their addiction and 
still prescribed psychoactive drugs such as sedatives 
or Valium. 



This gap between evidence and practice is 
particularly acute for adolescents because of the 
critical importance of prevention and early 
intervention in this population. Screening and 
intervention services by health professionals for 
adolescents rarely is part of routine practice 
despite the abundance of guidelines and 
recommendations for screening this population; 
the knowledge that nearly three out of four high 
school students have used tobacco, alcohol or 
other drugs; and the availability of effective 
interventions. 12 

Current Practices Related to Tobacco. The 

majority (68.8 percent) of adults who are current 
smokers report that they want to quit smoking, f 
yet less than half (48.3 percent) of smokers who 
saw a health professional in the past year 
reported receiving advice to quit. 1 13 A survey 
of 6 th " through 12 th -grade students found that 
64.5 percent reported that in the past year no 
medical doctor, dentist or nurse asked them 
whether they smoked cigarettes, 8 14 even though 
screening and interventions by health 
professionals can have a substantial impact on 
young smokers. 15 

A large-scale analysis of national data" of 
clinical preventive services delivered to 
asymptomatic patients in clinical settings 
estimates that only 35 percent of the population 
receives tobacco screening and brief 
interventions in accordance with the 



' 52.4 percent of current and former smokers (those 
who quit smoking in the past year for six months or 
longer) had made a quit attempt that lasted longer 
than one day in the past year; however, only 6.2 
percent report that they have quit successfully. 
* Medicare beneficiaries were the most likely to 
receive smoking cessation advice (59.0 percent) and 
those without health insurance were the least likely to 
receive smoking cessation advice (35.3 percent). 
§ CASA Columbia's analysis of data from that survey 
found that, of those who smoked, only 21.4 percent 
said that these health professionals told them to stop 
smoking. 

** Including the National Health Interview Survey 
(NHIS), the Behavioral Risk Factor Surveillance 
System (BRFSS) and the Healthcare Effectiveness 
Data and Information Set (HEDIS) performance data. 



...Primary care physicians do not routinely 
provide any comprehensive screening for 
substance use disorders. . . [When they do provide 
treatment referrals, however, some encounter] 
addiction treatment services as a "black hole ". . . 
They are not informed of patient progress, 
treatment completion or non-completion or 
recommendations for continuing care. This 
contrasts significantly with referrals to other 
specialists wherein the treatment is regularly 
communicated and a collaborative relationship is 
maintained. 10 



-201- 



recommendations of the United States 
Preventive Services Task Force (USPSTF). 16 

Another study found that while physicians knew 
of their patients' smoking status at 68 percent of 
office visits, they provided smoking cessation 
counseling at only 20 percent of visits by 
smokers. 17 Analysis of national data found that 
physicians provided counseling in 22.5 percent 
of visits by current adult tobacco users; only 2.4 
percent of current tobacco users were prescribed 
medications for smoking cessation.* 18 A 
national survey of medical professionals- 
including primary care physicians, emergency 
medicine physicians, psychiatrists, registered 
nurses, dentists, dental hygienists and 
pharmacists— indicates that whereas most report 
asking patients if they smoke and advising those 
who smoke to quit, they are much less likely to 
follow through with assessments or referrals to a 
smoking cessation program. 19 

A study of physicians in family medicine, 
internal medicine, obstetrics/gynecology and 
psychiatry found similar results. Although most 
(86 percent) report asking patients about their 
smoking and advising them to quit, few do much 
more than that: only 1 7 percent said they 
usually arrange for a follow-up visit to address 
the patient's smoking and only 13 percent said 
they usually refer patients who smoke to 
appropriate treatment. 20 One study found that 
pulmonologists, cardiologists and family 
physicians were the physician specialists most 
likely to be familiar with resources regarding 
treatment for addiction involving nicotine and 
most likely to refer patients to treatment, 
whereas psychiatrists, neurologists, 
ophthalmologists and surgeons were the least 
likely to have such familiarity or to refer 
patients. 21 

A survey of clinical psychologists found that 
one-third (32.3 percent) had not thought about 
offering smoking cessation counseling to their 
patients. 22 And although most registered nurses 
ask patients about smoking (87.3 percent), only 
65.6 percent advise those who smoke to quit and 



Both female patients and patients ages 65 and older 
were less likely to be prescribed medication. 



less than half offer interventions (49.4 percent 
provide materials with quitline information and 
34.0 percent refer the patient to a smoking 
cessation program). 23 Another national survey 
of nurses' interventions with patients who 
smoke found similar results. ' 24 

While the U.S. Clinical Practice Guideline on 
Treating Tobacco Use and Dependence 
encourages dental clinicians to screen their 
patients for tobacco use 25 and has been 
promulgated widely by the United States Public 
Health Service and the Agency for Healthcare 
Research and Quality, approximately three in 10 
dental professionals still do not advise patients 
who smoke to quit and approximately three- 
quarters do not refer a patient who smokes to a 
smoking cessation program. 26 This is despite the 
fact that many patients expect their dentists to 
inquire about their smoking status and to discuss 
smoking cessation with them; 30 percent of 
dental patients report that they would try to quit 
smoking if their dentist suggested they do so. 27 
Dentists who implement an effective smoking 
cessation intervention can expect that up to 10 to 
1 5 percent of their patients who smoke will quit 
in a given year. 28 

Pharmacists, as a profession, rarely provide 
tobacco cessation counseling; only about seven 
percent of patients report being asked by a 
pharmacist about tobacco use. 29 This is in spite 
of the facts that pharmacists are one of the most 
accessible groups of health professionals and 
they work in settings frequented by smokers and 
where tobacco cessation products are available. 30 
The majority of smokers (83 percent) believe 
that pharmacists should be involved in providing 
smoking cessation interventions, 73 percent 
would join a smoking cessation program offered 
at a conveniently-located pharmacy 31 and 63 
percent who already use nicotine replacement 
therapy (NRT) believe that smoking cessation 
counseling by pharmacists would increase a 



' Seventy-three percent frequently asked patients 
about tobacco use and 62 percent advised patients 
about quitting. Only 24 percent of nurses 
recommended medications to patients for cessation, 
22 percent referred patients to cessation resources 
and 10 percent recommended use of a quitline. 



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smoker's likelihood of being able to quit. 32 
Something as simple as keeping NRT products 
behind the pharmacy counter where customers 
would have to ask for them, or within view of 
the pharmacist but accessible to customers, is 
related to a greater likelihood of pharmacist- 
initiated smoking cessation counseling. In one 
study, pharmacists who stored NRT products 
behind the counter were 4.7 times likelier to 
provide counseling ' than pharmacists who stored 
the products out of customers' sight; those who 
stored them within view but still accessible to 
customers were three times likelier to offer 
counseling than those who stored them out of 
customers' sight. 33 

Current Practices Related to Alcohol and 
Other Drugs. A national survey of patients 
who had visited a general medical provider in 
the past year found that only 29 percent were 
asked about alcohol or other drug use; 9.2 
percent were given the suggestion to stop using, 
13.6 percent were given a brief intervention and 
5.3 percent were referred to counseling. Of 
those in the sample who reported having been 
asked by a general medical provider about their 
alcohol or other drug use and were identified as 
risky drinkers, less than half (48.6 percent) 
received any type of advice from their doctor 
concerning their substance use. 34 

Another study found that 19.6 percent of 
patients who were identified by primary care 
practitioners as misusing addictive substances 
but who were not diagnosed with addiction did 
not receive a recommendation for an active 
intervention. 35 

A national survey of current and former 
drinkers, ages 18-39 years, found that 67 percent 
saw a physician in the past year but only 49 
percent of excessive drinkers 1 were asked about 



This approach might be less likely to deter 
customers from purchasing the NRT products, since 
some smokers may be hesitant to ask for assistance. 
' To four or more customers per month. 
* Those exceeding the National Institute on Alcohol 
Abuse and Alcoholism's (NIAAA) guidelines of no 
more than four drinks per day or 14 drinks per week 
for men and no more than three drinks per day or 
seven drinks per week for women. 



their drinking and only 2 1 percent of them were 
counseled about risky drinking. 5 While 
respondents ages 18-25 years were most likely 
to engage in excessive drinking, they were least 
likely to be asked about their alcohol use (34 
percent of excessive drinkers ages 1 8 to 25 years 
vs. 54 percent of excessive drinkers ages 26 to 
39 years). 36 

Efforts to educate patients and connect them 
with needed services also are inadequate in 
emergency departments (EDs). 37 The American 
College of Surgeons Committee on Trauma 
designated alcohol and other drug screening as 
an "essential diagnostic test" at Level I and 
Level II trauma centers, 38 yet many trauma 
centers do not provide any screening or brief 
intervention services for those who may need 
them. 39 A national survey of ED directors found 
that only 1 5 percent reported having formal 
screening and intervention policies in their EDs. 
While nearly two-thirds (64.5 percent) reported 
routinely screening for risky alcohol use via a 
serum alcohol level and 23.6 percent reported 
using standardized screening instruments, only 
nine percent reported offering brief interventions 
by trained personnel for risky alcohol use. 40 

Although the majority of surgeons (89 percent) 
say that alcohol is a major burden on their 
trauma center (an estimated 40 to 50 percent of 
trauma patients have positive blood alcohol 
levels) 41 and 76 percent consider other drug use 
to be a significant burden, 42 trauma center and 
ED physicians often fail to address the 
underlying alcohol and other drug problems that 
cause patients' injuries. 43 

Despite evidence of the effectiveness of ED- 
based screening and brief interventions for 
substance-using adolescents, 44 a study of 
adolescents admitted to hospitals following 
trauma injuries in which 15.5 percent screened 
positive for alcohol in their blood found that 
only 59 percent of those who screened positive 
were referred for intervention services. 45 



14 percent were advised about low-risk drinking 
guidelines and seven percent were advised to cut 
down. 



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Assessment, Stabilization and Acute 
Treatment 

Despite the existence of effective assessment, 
stabilization and treatment options, addiction 
treatment today for the most part is not based in 
the science of what works. 46 Depending on 
disease stage and a range of other health and 
social factors, some people with addiction may 
be able to stop using addictive substances and 
manage the disease with support services only; 
however, most individuals with the disease 
require clinical treatment. 47 The failure of many 
providers to properly assess the stage and 
severity of the disease and provide effective 
psychosocial and pharmaceutical therapies 
appears in large part to be due to a lack of 
appropriate education and training.* 48 

While physicians are somewhat better at 
assessing tobacco use among their patients and 
discussing options for treatment, there is still 
much room for improvement. A recent national 
survey found that approximately two-thirds of 
primary care physicians (68.5 percent) and 
psychiatrists (63.8 percent) report discussing 
medication options for smoking cessation with 
their patients, as do 22.6 percent of dentists and 
14.5 percent of emergency medicine 
physicians. 49 

CASA Columbia's 2000 survey of physicians 
and patients found that 94 percent of primary 
care physicians (excluding pediatricians) failed 
to identify addiction as a possible diagnosis 
when asked to offer five possible diagnoses of a 
patient with symptoms of risky alcohol use. 
Most patients responding to that survey (53.7 
percent) reported that their primary care 
physician did nothing about their addiction; 10.7 
percent said their physician knew about it and 
still did nothing. The majority of patients (74.1 
percent) said their primary care physician was 
not involved in their decision to seek treatment 
and 16.7 percent said their physician was 
involved only "a little." 50 

CASA Columbia's research also found that 40.8 
percent of pediatricians failed to diagnose 



See Chapter IX. 



addiction when presented with a classic 
description of an adolescent patient with 
symptoms of addiction involving drugs (other 
than nicotine or alcohol). 51 However, another 
study found that, among adolescent patients 
diagnosed with addiction, primary care 
physicians recommended some type of follow- 
up 1 for 94.7 percent of the patients. 52 A study of 
adolescents admitted to an inpatient psychiatric 
unit 1 found that one-third met clinical criteria for 
addiction, but outpatient clinicians had not 
identified addiction in any of these patients 
before admission to the inpatient unit. 53 

Other research found that only 1 3 percent of 
patients who received an addiction-related 
diagnosis while visiting an ED received follow- 
up addiction treatment services within two 
weeks of the visit. 5 More than 200 patients in 
the study had another ED visit within two 
months of their initial ED visit, 54 suggesting that 
hospitals do not appropriately address patients' 
addiction or provide them with referrals to 
treatment.** 55 A study of ED patients admitted 
with cocaine-related chest pain found that three- 
quarters (74.7 percent) had not received any 
treatment three months after discharge. 56 

Detoxification Frequently is Considered 
Treatment Rather Than a Precursor to 
Treatment. A minority of patients who 
participate in detoxification programs go on to 
receive treatment, despite evidence that 



' Defined in this study as any plan beyond periodic 
screening, including notification of parents, referral 
to counseling, return visit with the primary care 
physician or noting that the patient already was in 
counseling for substance use. 
* Patients were admitted to the unit for psychiatric 
conditions other than addiction. 
§ The primary diagnosis for patients included in the 
study was addiction for 28 percent of the sample, 
mental health issues for 13 percent of the sample and 
medical (non-psychiatric) disorders for 59 percent of 
the sample. 

** Another study found that patients with unmet 
addiction treatment needs are nearly twice as likely to 
be admitted to the hospital and nearly one-and-a-half 
times as likely to have made at least one ED visit in 
the past year compared to patients without unmet 
treatment needs. 



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treatment beyond detoxification typically is a 
medical necessity. 57 In 2008,* only 12.6 percent 
of discharges from detoxification programs 
transferred to a treatment facility. About one in 
10 (10.8 percent) of alcohol detoxification 
discharges were transferred to a treatment 
facility, as were 20.7 percent of marijuana 
detoxification discharges, 13.6 percent of other 
illicit drug detoxification discharges,' 18.2 
percent of prescription drug detoxification 
discharges and 13.9 percent of multiple 
substance detoxification discharges. 58 Another 
study found that only 32.8 percent of Medicaid- 
enrolled adult patients discharged from 
detoxification received follow-up care within 30 
days of discharge. 1 59 

Addiction Treatment Rarely Addresses 
Smoking. Although recent scientific evidence 
underscores the unitary nature of the disease of 
addiction and the consequent need to address 
addiction involving all substances, 60 many 
addiction treatment providers continue to 
address addiction involving alcohol, illicit drugs 
and controlled prescription drugs while largely 
ignoring addiction involving nicotine. 61 

Smoking cessation services are not commonly 
implemented in addiction treatment settings 62 or 
in psychiatric treatment settings. 63 

The reluctance to provide smoking cessation 
services to patients in treatment for addiction 
involving alcohol or other drugs stems in part 
from an unfounded concern that it might 
jeopardize patients' ability to abstain from 
alcohol or other drug use. 64 There is no 
evidence that quitting smoking interferes with 



Most recent available data. 
' 19.4 percent of opioid (other than heroin) 
detoxification discharges, 16.4 percent of 
cocaine/crack detoxification discharges and 12.4 
percent of heroin detoxification discharges 
transferred to a treatment facility. 
* This disparity stems in part from financial 
constraints. Some insurance plans pay only for 
medical detoxification but not for addiction treatment 
including psychosocial and pharmaceutical therapies. 
Some plans that do cover both detoxification and 
treatment manage them separately, making continuity 
of care difficult. 



the effectiveness of treatment for addiction 
involving alcohol or other drugs. 65 In fact, 
research shows improved addiction treatment 
outcomes among patients who receive smoking 
cessation services, including reduced risk of 
relapse following treatment and improved 
outcomes for co-occurring addiction involving 
alcohol. 66 In light of this evidence, some states 5 
are banning smoking in addiction treatment 
facilities and requiring that smoking cessation 
services be provided to patients. 67 Making 
smoking cessation a key component of addiction 
treatment programs would go a long way toward 
improving treatment outcomes as well as the 
long-term health of patients with addiction. 68 

One study found that fewer than half (43 
percent) of addiction treatment programs in the 
United States offer formal smoking cessation 
services; no data are available on the extent to 
which nicotine addiction is fully integrated into 
these treatment programs." Among those that 
do offer cessation services, more offer 
pharmaceutical interventions than psychosocial 
interventions (37 percent vs. 18 percent). 69 

Although rates of smoking among adolescent 
addiction treatment patients are high and 
effective interventions are available, 70 less than 
half (42.8 percent) of treatment programs 
designed specifically for adolescents offer 
smoking cessation services; 13 percent offer a 
comprehensive formal program with 
pharmaceutical therapy, 15.3 percent offer 
counseling only and 14.5 percent offer 
pharmaceutical therapy only. 71 

Less than 20 percent of addiction treatment 
providers received any training in smoking- 
related issues in the past year. 72 This is despite 
the fact that the majority (between 65 and 87 
percent)' 1 of patients in addiction treatment 



5 NY, NJ, WA. 

CASA Columbia's survey of directors of addiction 
treatment programs in New York State found that the 
majority (89.2 percent) indicated that treatment for 
addiction involving nicotine is offered in their 
addiction treatment programs. 
' r Data based on a review of several studies. 



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programs smoke— a rate more than three times 
that in the general population. 73 

Pharmaceutical Treatments are 
Underutilized. A key factor in integrating 
addiction treatment into mainstream medicine is 
broader implementation of pharmaceutical 
interventions, when indicated. 74 Yet providers 
of addiction treatment vastly underutilize 
evidence-based pharmaceutical therapies. 75 

CAS A Columbia's survey of directors of 
addiction treatment programs in New York State 
found that less than half (47.0 percent) indicated 
that pharmaceutical treatments are offered in 
their addiction treatment programs. 76 

A national longitudinal survey of programs that 
offer addiction services* found that the 
percentage of programs offering nicotine 
replacement therapy (NRT) decreased 
significantly from 38.0 percent during 2002- 
2004 to 33.8 percent four years later. Programs 
were more likely to continue offering NRT if 
they were medically oriented (i.e., located in a 
hospital setting with access to physicians). 77 

Underutilization of pharmaceutical treatments is 
particularly common in treatment programs that 
are publicly funded, small, not located in a 
hospital, not accredited' and have few medical 
professionals-including physicians and nurses— 
on staff 78 National data indicate that among 
privately- and publicly-funded treatment 
programs, approximately half have adopted at 
least one pharmaceutical treatment for 
addiction. 1 79 



Including privately-funded treatment organizations, 
publicly-funded treatment organizations and 
therapeutic communities. 

' By the Joint Commission or the Commission on 
Accreditation of Rehabilitation Facilities (CARF). 
(See Chapter IX for a description of these accrediting 
organizations.) 

* Approximately 51 percent of privately- funded 
programs and 25 percent of publicly-funded 
programs adopted buprenorphine in their treatment of 
addiction, 40 percent of private programs and 19 
percent of public programs adopted acamprosate or 
tablet naltrexone, 30 percent of private programs and 
16 percent of public programs adopted disulfiram and 



The limited adoption of pharmaceutical 
treatments for addiction, when indicated, is due 
in large part to a lack of qualified medical staff 
in addiction treatment programs to prescribe and 
monitor medication protocols. 80 Thirty-eight 
percent of publicly-funded programs do not even 
have access to a prescribing physician, nor do 23 
percent of privately-funded programs. 81 

Treatment providers seem to have more negative 
attitudes toward the use of pharmaceutical 
therapies relative to psychosocial therapies. 82 
Some treatment programs see pharmaceutical 
treatments for addiction, such as the use of 
methadone maintenance treatment for addiction 
involving opioids, as incompatible with 
abstinence-based treatment approaches; 83 there 
is a stigma among some providers attached to 
the use of pharmaceuticals to achieve abstinence 
from a drug to which the patient is addicted. 
One of the key predictors of the underutilization 
of pharmaceutical treatments is adherence of 
treatment providers to a strong 12-step ideology 
for addiction treatment. 84 

CASA Columbia's survey of treatment providers 
in New York State found that respondents were 
more likely to say that recreational therapy/ 
leisure skills training is a "very important" 
intervention for a treatment facility to offer to 
patients 5 than to say the same of pharmaceutical 

** 85 

treatments. 

Addiction treatment medications also may be 
underutilized by physicians themselves due in 
part to insufficient evidence regarding optimal 
dosages of certain pharmaceutical therapies, 
durations of use, how to combine the use of 
medications with counseling and the 



less than 20 percent of private programs and less than 
10 percent of public programs adopted injectable 
naltrexone in their treatment protocols. 
§ 51.8 percent of program directors, 54.7 percent of 
staff providers. 

28.0 percent of program directors, 33.8 percent of 
staff providers for methadone maintenance treatment 
and 43.9 percent of program directors, 45.7 percent 
of staff providers for other medication treatments for 
addiction such as buprenorphine, disulfiram or 
naltrexone. 



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generalizability of research-based efficacy 
findings to different patient populations. 86 

Although one study found that each additional 
physician on staff in a treatment program was 
associated with a doubling of the odds that the 
program would adopt the use of pharmaceutical 
treatments for addiction, 87 having access to a 
staff physician does not guarantee access to or 
use of pharmaceutical treatments. 88 One study 
found that 82 percent of publicly-funded 
addiction treatment programs with access to a 
physician did not prescribe any treatment 
medications for addiction involving alcohol; the 
same is true of 4 1 percent of privately-funded 
treatment programs with access to a prescribing 
physician. 89 

The treatment of addiction involving opioids 
presents one of the most glaring examples of the 
underutilization of clinically-effective and cost- 
effective pharmaceutical treatments for 
addiction. 91 Buprenorphine is a pharmaceutical 
treatment for addiction involving opioids that, 
despite a rich body of evidence demonstrating its 
efficacy, safety 92 and cost effectiveness, 93 is 
significantly underutilized in practice. 94 The 
majority (86 percent) of addiction counselors 
report not being aware of the effectiveness of 
buprenorphine. 95 



We 're seeing less interest [in prescribing 
buprenorphine] than we expected, especially 
among primary care physicians. 96 

-Robert Lubran, MPA 
Director 

Division of Pharmacological Therapies 
Center for Substance Abuse Treatment (CSAT) 

SAMHSA 



Specific additional obstacles to the widespread 
use of buprenorphine by physicians include cost, 
lack of insurance coverage and availability 
problems due to pharmacies not stocking the 
medication. 97 

Physicians' biases against patients with 
addiction may contribute to the limited adoption 
of pharmaceutical treatments as well. 98 Survey 
results from a random sample of internal 



medicine, family medicine, psychiatry and pain 
management physicians in Maryland found that 
only 36 percent of respondents were willing to 
prescribe buprenorphine to an established patient 
and only 28 percent were willing to prescribe the 
medication to a new patient. Seventeen percent 
of physicians unwilling to prescribe the 
medication said that addiction involving opioids 
is best described as a habit rather than an illness; 
none of the physicians willing to prescribe the 
medication agreed with this statement. Half of 
the Maryland doctors who were not willing to 
prescribe buprenorphine reported that they 
believe that treatment for addiction involving 
opioids is beyond the scope of practice of office- 
based physicians and 46 percent reported not 
wanting patients with addiction involving 
opioids in their clinics. 99 



The reason I am not interested [in prescribing 
buprenorphine] is / see this as an opportunity for 
drug users who are by class the most lying, 
scheming, dishonest group of patients. They need 
hard-based, no-nonsense treatment programs. I 
can't stand their manipulative behavior. 90 

Anonymous Physician 



The fact that buprenorphine can be prescribed in 
physicians' offices for at-home use was heralded 
as a step forward in the treatment of addiction 
involving opioids. Addiction professionals 
anticipated the medication's potential to help 
addiction treatment become a more central 
component of medical practice. 101 However, 
these hopes have not come to fruition. 102 



There is no other comparable example in 
medicine where you have evidence-based 
treatments that are not available. 100 

-Shelly Greenfield, MD, MPH 
Chief Academic Officer, McLean Hospital 
Professor of Psychiatry, 
Harvard Medical School 
Director, Clinical and Health Services Research 
and Education Division of Alcohol 
and Drug Abuse, McLean Hospital 



-207- 



Nutrition and Exercise Are Not Integrated 
into Addiction Treatment. Although good 
nutrition and exercise are important components 
of comprehensive addiction treatment* 103 - 
particularly in light of recent research 
underscoring common brain circuitry involved 
in substance-related addiction and obesity 104 ~the 
extent to which nutrition and exercise are 
incorporated into addiction treatment has not 
been examined. One small study' found that 56 
percent of dietitians and nutrition program 
managers working in addiction treatment 
facilities reported that their facilities offered 
nutrition-related addiction education in group 
settings to only about half of their patients. 
Fifty-six percent of respondents reported 
offering nutrition-related addiction education in 
individual settings to an average of 1 8 percent of 
their patients. 105 

Formal Treatment Is Conflated with Support 

Services. The overwhelming salience and 
considerable evidence-although largely 
anecdotal-of the benefits of mutual support 
programs like Alcoholics Anonymous (AA), for 
example, have led many people to conflate such 
support services with actual addiction treatment 
rather than to recognize them as highly useful 
systems of support that should accompany or 
follow evidence-based clinical treatment. * 106 
Mutual support programs are facilitated by 
members whose main credential is that they 
themselves have experienced an addictive 
disorder and have learned to manage it. Such 
support, however, is quite different than 
treatment for a medical condition. 5 107 Few 
would argue that any other disease be treated 



See Chapter V. 
' Using a non-randomized sample. 
* There are some exceptions where, depending on the 
severity of disease symptoms and the patient's health 
status and degree of social support, certain patients 
are able to manage their addiction with support 
services only or no interventions at all. In addition, it 
should be noted that Twelve-Step Facilitation, 
discussed in Chapter V, is a formalization and 
professionalization of the 12-step mutual support 
model and has been deemed an evidence-based 
treatment for addiction. 

§ AA openly recognizes addiction as a medical 
condition. 



solely via support groups composed of those 
who themselves have had the condition. 

Tailored Treatment Services 

Whereas research clearly indicates that to be 
effective interventions should be tailored not 
only to the stage and severity of a patient's 
illness but also to a patient's co-occurring 
conditions and other personal characteristics and 
life circumstances that might affect treatment 
outcome, most health professionals and 
addiction treatment programs follow a one- size- 
fits-all approach to treatment. 

Disease Severity Rarely is Assessed and 
Interventions Rarely are Tailored to Stage 
and Severity of Disease. It is standard 
recommended medical practice to assess the 
stage and severity of a patient's disease in order 
to develop an effective treatment plan and tailor 
treatment accordingly. 108 Assessment of disease 
severity is an essential part of addiction 
treatment as well. 109 One of the most widely- 
used tools, both in research and clinical practice, 
for assessing the severity of addiction is the 
Addiction Severity Index, although even this 
instrument fails to address addiction involving 
nicotine. 110 Yet, the extent to which treatment 
providers tailor treatment protocols based on the 
findings of such assessments is limited. 111 
Instead, addiction treatment programs typically 
utilize a non-tailored approach to patient care. 112 

Having patients pass through a rigid, time- 
limited treatment program that assumes 
uniformity in disease symptoms and severity 
simply burdens patients with unnecessarily 
extensive interventions or with interventions that 
are too brief or superficial to have a significant 
impact on their symptoms. Yet the standard 
treatment for addiction is non-intensive 
outpatient treatment, 113 often without adequate 
professional follow-up care and disease 
management. Even residential treatment 
typically is limited to a 28-day stay in a program 
despite little evidence that the condition remits 
after such a brief period of time. 114 Given this 
standard approach to treatment that focuses 
primarily on acute care only, it is little wonder 
that relapse is so common and that addiction 



-208- 



continues to be seen as an intractable condition 
largely resistant to treatment. 



We are treating these folks with severe and 
persistent addiction with a time limited-treatment 
of three or four weeks, maybe six or eight, maybe 
at the most three months, if you want to include 
what's called aftercare. Now, why would we think 
that treating a chronic disorder for a few weeks 
would lead to improvement 10 years later or five 
years later or even a year later? It doesn 't make 
any sense. 115 

-Mark Willenbring, MD 
Director, Division of Treatment and Recovery 
National Institute on Alcohol 
Abuse and Alcoholism 
(currently, Associate Professor of Psychiatry, 
University of Minnesota) 



Interventions Do Not Adequately Address 
Co-occurring Conditions. In standard medical 
practice, it is recommended that health 
professionals assess the presence of co-occurring 
conditions in order to develop an effective 
treatment plan and tailor treatment 
accordingly. 116 Although such assessments are 
critical in addiction treatment given the very 
high rate of co-occurring conditions in people 
with addiction, treatment programs frequently 
do not address co-occurring health conditions or 
do so in a suboptimal way. 117 

Implementing a one-size-fits-all approach to 
treatment based solely on a clinical diagnosis 
without consideration of co-occurring health 
conditions often amounts to a waste of time and 
resources. CASA Columbia's survey of 
directors of addiction treatment programs in 
New York State found that less than half (48.2 
percent) of the program directors indicated that 
treatment for co-occurring mental and physical 
health disorders is offered in their programs. 118 

A recent study of patients in residential 
treatment for addiction who had co-occurring 
mental health conditions underscores the 
importance of tailoring treatment to the needs of 
the patient population. In this study, those with 
co-occurring mental health conditions reported 
less satisfaction with treatment, saw fewer 



benefits to stopping their substance use, had less 
belief in their efforts to control their substance 
use to maintain abstinence and were less likely 
to employ positive coping skills than patients 
with addiction who did not have co-occurring 
mental health conditions. 119 



/ lost my son to addiction and ultimately suicide. 
From the time I knew he had a problem until the 
day he died, I tried everything at my disposal to 
help him get quality care. He went to eight 
different programs and they all had a different 
approach; many offered conflicting advice. 
Only four of them looked at Brian as a whole 
person; the other four only looked at his 
addiction. Only five included a comprehensive 
medical assessment; in fact, only three even had 
a full-time doctor on the premises. And 
although they each viewed his condition as a 
chronic disease requiring effective aftercare and 
long term management, none of them had an 
effective recommendation for this, nor any 
follow up from that program. In a letter to me 
during one of his stays in a residential program, 
he offered the insight that much of his previous 
rounds of treatment had addressed his addiction 
in isolation— as if it were unrelated to any 
underlying emotional problems. In the last 
weeks of his life, Brian was suffering from 
severe depression. On the day before he died, 
his aftercare program made the decision, 
without consulting Brian 's therapist, or his 
parents, to terminate their relationship with him. 
At the time Brian most needed help, he was left 
alone. And so was 1. 120 

-Gary Mendell, father 
Lost his son Brian, age 25, 
to addiction and suicide 



Although people with mental illness smoke at 
significantly higher rates than the general 
population, smoking cessation services rarely 
are provided by mental health treatment 
professionals. 121 Generally psychiatrists are less 
likely than family physicians to inquire about 
smoking, offer advice on quitting or assess 
patients' willingness to quit. 122 Yet, because 
individuals with severe mental illness interact 
with psychiatrists to a greater extent than with 
primary care physicians (who typically are the 
main referral source or provider of smoking 
cessation interventions), patients in mental 



-209- 



health settings who smoke may be even less 
likely to receive the smoking cessation services 
they need. 123 Psychiatrists may eschew smoking 
cessation interventions because they believe 
"patients have more immediate problems to 
address;" some medical and other health 
professionals also may be reluctant to encourage 
smoking cessation because they feel it "gives 
patients with psychiatric illnesses comfort while 
dealing with their mental illness symptoms." 124 
Contrary to these beliefs, research shows that 
smokers with mental health conditions are as 
motivated as those in the general population to 
quit smoking 125 and one study showed that the 
majority (79 percent) of mentally ill smokers 
want to quit. 126 

Interventions Rarely are Tailored to Patient 
Characteristics that Might Affect Treatment 
Outcomes. Not taking into account a patient's 
age, gender, race/ethnicity, socioeconomic status 
or system of personal supports in designing a 
treatment intervention can compromise 
otherwise effective treatment plans. 
Chapter VI of this report outlines specific 
treatment needs of special populations and 
Chapter VII shows the gaps in needed treatment 
for some of these groups. While the baseline 
level of addiction-related services offered to the 
general population is inadequate, the deficiency 
in tailored services offered to populations with 
special treatment needs is even more glaring. 127 

Chronic Disease Management 

For many individuals, addiction manifests as a 
chronic disease, requiring disease and symptom 
management over the long term. 128 In recent 
years, there has been growing recognition of the 
importance of comprehensive disease 
management in the treatment of chronic health 
conditions for which there is no known cure, 
where relapse episodes are considered an 
expected part of the disease course and where 
long-term symptom management is considered 
routine care. While this approach increasingly 
has been adopted for diseases such as 

1 29 1 30 131 

diabetes, hypertension and asthma, 
addiction treatment largely remains stuck in the 
acute-care model. 132 



Patients with addiction, regardless of the stage 
and severity of their disease, typically receive a 
diagnosis followed by a swift course of 
treatment administered by individuals without 
any medical training and then minimal to no 
follow-up care. 133 In contrast to other chronic 
diseases, positive results from a short-term 
intervention or treatment for addiction are 
expected to endure indefinitely and relapse 
commonly is viewed as a sign of treatment 
failure, at best, and as evidence of a deficit in 
patients' willpower or dedication to managing 
their condition, at worst, rather than as a result 
of inadequate treatment or follow-up care. 134 

Evidence of the acute care approach to addiction 
treatment is that current Medicare and Medicaid 
regulations indicate that hospital readmissions 
for patients with addiction involving alcohol are 
not to be treated as extensions of the original 
treatment but rather as a new admission to treat 
the same condition. Readmissions can be seen 
as evidence that treatment is not working and 
typically are not covered unless a physician can 
document a change in the patient's physical, 
emotional or social condition that makes it 
reasonable to expect that additional treatment 
would improve the patient's condition, or 
documents why the initial treatment was 
insufficient. 135 Given that addiction often is a 
chronic disease and that relapse is possible, 
limitations on hospital readmissions may reduce 
access to needed care and reflect a fundamental 
mischaracterization of the disease and its 
expected course of treatment. 



-210- 



Examples of the Evidence-Practice Gap in Addiction Treatment throughout History 

The use of addiction treatments that are not grounded in science has a long history. While most of these approaches have 
been discredited with time, some have proven to be prescient in their foreshadowing of current treatment approaches, both 
those that are evidence based and those that continue to profit from claims about being able to treat or even cure addiction in 
manners that largely are not based on scientific evidence. 

For example, in the late 1700s, Dr. Benjamin Rush, the "father of American psychiatry," was the first American doctor to say 
that "habitual drunkenness should be regarded not as a bad habit but as a disease" 136 that should be treated. 137 In the late 19 th 
century, medically -based addiction treatment mostly involved trying to cure individuals of their addiction, often with the use 
of other addictive substances. 138 

By 1910, private sanitariums in the United States offered specialized treatment for addicted individuals— but only for those 
who could afford the expense. Similar to today, many of the "treatment experts" opening facilities were savvy businessmen 
or enterprising physicians, including Harvey Kellogg (later of cereal fame) and Dr. Leslie E. Keeley. Between 1892 and 
1893, almost 15,000 people with addiction were treated at the famous, yet controversial Keeley Institutes. 139 Keeley's 
treatment for addiction involved bichloride of gold remedies, a substance purportedly containing gold that would cure 
addiction involving alcohol and opioids. The use of bichloride of gold became highly controversial and was opposed by the 
American Medical Association (AMA). After the death of Dr. Keeley in 1900, the popularity and ultimately, the existence of 
his institutes waned. 140 

Although Keeley's treatments were later discredited, his position that addiction was decidedly a disease rather than a 
religious or moral failing was ahead of its time. His use of "shot treatments" or hypodermic treatments that induced vomiting 
was a precursor to later aversion therapies and his introduction of clubs for addicted individuals to receive social support to 
maintain sobriety was a precursor to the mutual support programs that remain prominent today. His focus on helping people 
quit smoking in the 1920s was prescient in its characterization of nicotine as a harmful and addicting drug. 141 

Addiction treatment tactics that are based more on the personal charisma of the founders, catchy phrases and simplistic 
approaches than on the science of what works in addiction continue to proliferate and show no sign of waning. A simple 
Google search produces an abundance of "rehabilitation" approaches and facilities with slogans such as: Learn how to heal 
the underlying causes of dependency— and be free of addiction forever! 142 A recent study examining treatments that a panel 
of experts believes qualifies as quackery in addiction treatment found such treatments as electrical stimulation of the head, 
past-life therapy, electric shock therapy, psychedelic medication and neuro-linguistic programming to be "certainly 
discredited." 143 Nevertheless, unsubstantiated interventions continue to be used to this day, many of which prey upon the 
desperation of addicted individuals and their families. 

In the late 1930s and early 1940s, many hospitals would not admit patients for the treatment of addiction involving alcohol, 
so lay approaches became an important option. 144 Alcoholics Anonymous (AA), founded in 1935, was premised on 
laypersons addicted to alcohol helping one another overcome their addiction and related problems. 145 While the mutual 
support/self-help approach maintained the perspective of addiction as a disease— formalized in the development of the 
principles underlying the Minnesota Model in the 1950s— the "rehabilitative model" of treatment was seen as distinct from 
"the medical model." Standard medical interventions that normally would be applied to diseases were not a significant part 
of the treatment, nor were medical or other health professionals called upon to play key roles in treating the disease. 146 This 
model remains the dominant approach to addressing addiction in the United States. Yet, its limitations and failure to address 
addiction the way other diseases are addressed have led to a call to integrate addiction treatment into mainstream medical 
care. 



Based on the composite opinions of a panel of 75 experts regarding 65 addiction treatments which they rated on a 
continuum from "not at all discredited" to "certainly discredited." 



-211- 



Barriers to Closing the Evidence- 
Practice Gap 

America's approach to addressing risky 
substance use and providing addiction treatment 
has evolved outside of the mainstream public 
health and medical systems.* 147 As a result: 

• Most primary providers of intervention and 
treatment for risky substance use and 
addiction do not have the requisite training 
or qualifications to implement the existing 
range of evidence-based practices and face 
many organizational and structural barriers 
to providing services; 

• Most health professionals do not implement 
evidence-based addiction care practices; 

• Performance and outcome measures that 
should be a routine part of quality assurance 
in mainstream medicine are limited and 
rarely implemented in addiction treatment; 

• The pharmaceutical industry lacks the 
incentive to develop new and effective 
pharmaceutical interventions for addiction 
treatment; and 

• Insurance coverage for evidence-based 
intervention, treatment and disease 
management is inadequate. 

Because of the vast chasm between the health 
care system and approaches to preventing risky 
substance use or treating addiction, medical 
professionals fail to address risky substance use 
or addiction or take responsibility for 
intervention or treatment, risky substance use is 
addressed primarily in terms of its consequences 
and addiction treatment providers are not held to 
the same standards as providers of mainstream 
medical care. 



See Chapter IX for an in-depth discussion of the 
education and training requirements for those 
providing services for risky substance use and 
addiction. 



The lack of integration of screening and 
intervention and addiction treatment into 
mainstream health care has led to many missed 
opportunities to help patients who engage in 
risky substance use or who have addiction and 
has contributed to the high rates of relapse and 
enormous health and social consequences 
associated with risky use and addiction. 



The Addiction Treatment Workforce is Not 
Qualified to Implement Evidence-Based 
Practices 

For most illnesses, the preponderance of 
treatment interventions, including coordination 
of services, occurs within mainstream medicine 
and is provided and managed by trained medical 
professionals. Other highly-trained and 
credentialed health professionals may be part of 
a team of providers working with a physician. 
Motivated and experienced non-professionals 
may serve additional vital functions-such as 
providing social support to encourage adherence 
to a treatment plan and help patients maintain 
important lifestyle changes that can reduce the 
risk of relapse-but their roles and services do 
not supersede or replace those of the medical 
team. 

In contrast, the majority of care for individuals 
with addiction is provided by people without any 
medical training at all and rarely is supervised 
by medical professionals. Physicians and other 
medical professionals typically are absent from 
or on the periphery of the treatment process, 
occasionally being called in to provide a 
prescription or medically monitor a 
detoxification protocol. 



One of the fundamental barriers to providing 
effective treatment is the fact that addiction is 
not integrated into medical practice. And a lot 
of medical people like and want it that way; they 
do not want to deal with addiction; they do not 
like to deal with the people and they do not feel 
effective addressing the problem. 148 

—Keith Humphreys, PhD 
Professor 
Stanford Medical School 



-212- 



Addiction treatment services primarily are 
provided through community-based treatment 
programs that were established in the 1970s and 
1980s before the medical model gained support 
and changes in the financial structure led to 
increasing demands for accountability and 
efficiency. 149 The treatment provider workforce, 
although frequently highly dedicated, is 
composed primarily of certified alcoholism and 
substance abuse counselors (CASACs)— a 
profession for which a college degree typically 
is not required and in which counselors receive 
limited on-the-job training in evidence-based 
practices 



150 



The result is that much of the current treatment 
provider workforce is not equipped to provide 
consistent evidence-based treatment, including 
administering and monitoring medication 
protocols, implementing complex psychosocial 
interventions, addressing co-occurring health 
conditions or responding to medical 
problems that may arise among 
individuals undergoing addiction 
treatment. 151 



providers) said substance abuse counselors 
(CASACs); 16.3 percent of directors and 17.8 
percent of staff providers said social workers, 
7.5 percent of directors and 6.7 percent of staff 
providers said psychologists and only 1.3 
percent of directors and 1.5 percent of staff 
providers said physicians. 153 

Only 9.9 percent of program directors and 13.7 
percent of staff providers indicated that a 
medical degree is a "very important" 
qualification for treatment providers to have; 3.7 
percent of directors and 6.5 percent of staff 
providers thought that way about a doctoral 
degree. A quarter (24. 1 percent of directors and 
26. 1 percent of staff providers) felt that a 
master's degree was a very important 
qualification, and about a quarter (26.8 percent 
of directors and 27.3 percent of staff providers) 
felt that way about a college/bachelor's 
degree. 154 (Figure 10.A) 



CASA Columbia's survey of addiction 
treatment providers in New York State 
provides a case in point. It found that 
37.2 percent of staff providers do not 
have a bachelor's degree' and only 
67.5 percent of program directors and 
35.0 percent of staff providers have a 
graduate degree of any type. 152 

Further, most treatment providers see 
the current state of affairs with regard 
to the staffing of treatment programs as 
reasonable. When asked which type of 
professional they think is best qualified to 
provide addiction treatment services, nearly 
three quarters of respondents to CASA 
Columbia's New York survey (71.3 percent 
program directors and 72.6 percent of staff 



Figure 10.A 

New York State Addiction Treatment Providers' Beliefs 
about the Importance of the Following Provider 
Educational Qualifications* 



26.8 27.3 



24.1 



26.1 



9.9 



13.7 




3.7 



6.5 



• Director 
i Staff 



College/Bachelor's Master's Degree Medical Degree Doctoral Degree 
Degree 

* Among those who responded that the educational qualification is "very 
important". 

Source: Casa Columbia Survey of New York State Addiction Treatment 
Providers, 2009. 



of 



In contrast, the majority of treatment providers 
in CASA Columbia's survey (61.4 percent of 
program directors and 76.3 percent of staff 
providers) thought that personal experience with 
addiction is an important qualification for 



See Chapter IX for specific credentialing 
requirements. 

29.9 percent had some college or an associate's 
degree, 6.6 percent had only a high school degree or 
GED and 0.7 percent did not complete high school or 
have a GED. 



-213- 



addiction treatment providers to have. 

CAS A Columbia's survey also found that only 
11.3 percent of program directors and 8.1 
percent of staff providers believe that the 
addiction treatment system "should be integrated 
into the medical system such that addiction is 
treated as a health condition by health care 
professionals." Two-thirds of directors (66.3 
percent) and 60.3 percent of staff providers, 
however, say that the addiction treatment system 
"should be two-tiered with health care 
professionals providing psychotherapeutic and 
pharmacological interventions and individuals 
with histories of addiction (in recovery) 
providing recovery support services." Fewer 
directors (7.5 percent) but more staff providers 
(21.3 percent) indicated that "the system should 
revolve around a recovery support model with 
self-help/mutual support programs as the main 
intervention." Fifteen percent of directors and 
10.3 percent of staff providers think that nothing 
about the system should change. 156 

Despite this variability in perceptions regarding 
what the treatment system should look like, 
there is general agreement that the current 
system is riddled with organizational and 
structural problems that impede the delivery of 
quality care, including inadequate financial 
resources, high staff turnover and restricted 
professional advancement. 157 While limited 
education and training of most providers and a 
treatment culture largely steeped in the self-help 
model stand in the way of adopting new, 
science-based practices, 158 organizational and 
structural problems within the current treatment 
system compound these limitations and further 
prevent the delivery of evidence-based care. 159 

CASA Columbia's survey of treatment providers 
in New York State found that respondents were 
most likely to cite a high volume of paperwork 



Among program directors, 28.9 percent said 
personal experience is slightly important, 25.3 
percent said it is moderately important and 7.2 
percent said it is very important. Among staff 
providers, 36.0 percent said personal experience is 
slightly important, 21.6 percent said it is moderately 
important and 18.7 percent said it is very important. 



(reporting requirements that take up too much 
time and resources), insufficient salaries to 
attract and retain high-quality staff, insufficient 
program funding and insufficient insurance 
coverage for patients as barriers that "very 
much" stand in the way of providers' ability to 
provide effective services to people in need of 
addiction treatment— reflecting both frustration 
with organizational barriers to quality care and a 
non-medical approach to treatment. An 
insufficient number of trained medical-level 
(MD/DO) professionals was least likely to be 
named by providers as a barrier that "very 
much" stands in the way of providing effective 
treatment services. 160 (Table 10.1) 



Table 10.1 

New York State Addiction Treatment Providers' Opinions 
of Barriers that "Very Much" Stand in the Way of 
Providing Effective Addiction Services 





Program 


Staff 




Directors 


Providers 


High volume of paperwork/reporting 






requirements 


76.8 


72.7 


Insufficient salaries to attract and retain 


74.7 


69.8 


high-quality staff 






Insufficient program funding 


62.2 


63.3 


Insufficient insurance coverage 


60.2 


61.6 


Insufficient number of appropriately trained 






staff with the qualifications necessary to 
provide treatment for co-morbid conditions 


56.1 


37.4 


Insufficient number of trained master's- 


28.0 


20.9 


level professionals 






Insufficient number of appropriately trained 






staff with the qualifications necessary to 
provide pharmacological therapies 


26.5 


19.7 


Limited motivation among staff members to 






be knowledgeable about evidence-based 


24.1 


19.7 


best practices 






Insufficient professional standards related 
to knowledge and clinical skills for 


20.5 


21.7 


individuals providing addiction treatment 






Insufficient federal- or state-level education 






and training requirements for individuals 


18.1 


23.2 


providing addiction treatment 






Insufficient access to information about 


13.3 


15.9 


best practices 






Insufficient number of trained medical-level 


12.3 


13.0 


(MD/DO) professionals 







Source: CASA Columbia Survey of New York State Addiction 
Treatment Providers, 2009. 



-214- 



Most Addiction Treatment Providers Do Not 
Adopt Evidence-Based Practices.* Many 
addiction treatment providers address addiction 
in ways that have not been evaluated or proven 
effective. While this is due in part to the 
inadequate education and training of treatment 
providers in evidence-based practices, 161 the 
larger issue is the significant mismatch between 
the qualifications that are necessary for 
implementing many evidence-based practices 
and the qualifications that the majority of the 
treatment workforce currently possesses. 162 
Because most treatment providers are not 
adequately trained, they are not capable of 
performing health assessments, prescribing 
pharmaceutical medications, treating co- 
occurring health conditions or managing a 
chronic disease, each of which is an essential 
evidence-based addiction treatment practice. 163 
Most also are not trained in the scientific method 
or clinical research, further impeding their 
ability to integrate clinical research findings into 
treatment practice. 164 

Education and awareness about evidence-based 
practices, however, are not sufficient to ensure 
proper implementation of those practices; 165 
additional steps are necessary to translate 
evidence into practice. Although significant 
progress has been made in the past decade in 
disseminating knowledge about evidence-based 
practices and improving attitudes toward them, 
less is known about how well such practices are 
implemented in treatment facilities and 

166 

programs. 

One study found that treatment programs that 
are most likely to adopt clinical and practice 
guidelines, including the use of standardized 
assessment tools, are those that offer a broad 
range of services-medical services, counseling, 
pharmaceutical therapy and support services- 



and those that receive funding from managed 
care organizations. ' 167 



1 Programs with managed care involvement were less 
likely to be freestanding facilities and more likely to 
be associated with multi-service hospital or medical- 
based clinics. They also were more likely to have 
staff with advanced degrees and less likely to have 
staff in recovery. The authors of this study speculate 
that programs with managed care contracts might be 
likelier than those without such contracts to be 
encouraged to have standardized practices. 



Evidence-based practice involves the use of current 
evidence in making decisions about patient care. 
Evidence-based practices aim to combine the best 
available research and clinical judgment while taking 
into account patient characteristics and needs. 

-215- 



We have entered the world of showing providers 
what is evidence based. Now we must show 
providers how to implement it... We haven't 
effectively brought practical research results to 
individual providers... so they can use if. 168 

—William H. Janes 
Former Director 
Florida Office of Drug Control 
Office of the Governor 

Evidence from research findings is not generally 
accessible and understandable to providers; 
we 're failing miserably at that. 169 

-Joseph M. Amico, MDiv 
President 

National Association of Lesbian and Gay 
Addiction Professionals 
(now Vice President, and association now called 
The Association of Lesbian, Gay, Bisexual, 
Transgender Addiction Professionals 
and Their Allies) 

According to the American Psychological 
Association, evidence-based practice is the 
integration of the best available research and 
clinical expertise within the context of patient 
characteristics, culture, values and preferences. 
Today we have a few places trying to implement 
these practices but with major limitations; few 
ever implement the practice the way it was 
researched.™ 

-Stephanie Covington, PhD, LCSW 
Co-Director 
Center for Gender and Justice 
Institute for Relational Development 
La Jolla, CA 



One study found that support staff*— who make 
up 24 percent of the treatment provider 
workforce in the National Institute on Drug 
Abuse's (NIDA) Clinical Trial Network (CTN) T 
and have more direct patient contact than 
professional counselors and medical personnel- 
showed little enthusiasm for evidence-based 
practices; they also were more likely to support 
intervention techniques that employ 
confrontation and coercion-techniques that 
contradict evidence-based practice. 171 In 
contrast, treatment providers affiliated with CTN 
who advocated for the use of new evidence- 
based practices tended to be more highly 
educated. 172 

A study of counselors' attitudes toward 
evidence-based psychosocial and pharmaceutical 
practices 4 found that those who had more 
specific training in the practices and those who 
worked in treatment centers where the particular 
practices were used routinely tended to perceive 
evidence-based practices as more acceptable for 
treating addiction. 173 Providers with higher 
educational degrees are more likely to be 
supportive of evidence-based practices than 
those with lower-level degrees. 174 In contrast, 
providers with a strong 12-step orientation to 
treatment tend to perceive evidence-based 
practices as less acceptable. 175 



For many recovering paraprofessional 
counselors, their counseling "trump card" is 
that their personal experience is exemplary of 

177 

how recovery works. 



Health Professionals do not Implement 
Evidence-Based Addiction Care Practices^ 

Mainstream medical and other health 
professionals do not adequately address risky 
substance use or the disease of addiction in their 
professional practice, in part because they are 
not trained to do so.** 176 and in part because 
they do not see it as a legitimate element of their 
role as health professionals. 

Education and training alone, however, is 
insufficient to change practice. For example, 
while numerous guidelines have been produced 
and disseminated by government agencies," 178 
professional associations 179 and quality 
improvement organizations such as the National 
Quality Forum (NQF) 180 and the Agency for 
Healthcare Research and Quality (AHRQ), 181 to 
help health professionals conduct evidence- 
based practices related to risky substance use 
and addiction, physicians and other health care 
providers commonly fail to adhere to these 
clinical practice guidelines. 182 

A recognized cadre of addiction physician 
specialists is essential to help educate and train 
other physicians, serve as equal partners in 
regular medical practice and provide specialty 

183 

care. 

Efforts also must be made to translate physician 
training into practice. A lack of time and 
resources make it difficult for physicians to 
remain up to date with the latest guidelines and 
recommendations, and limited reimbursement 
may prevent some physicians from taking the 
time to implement practice recommendations. 184 



Support staff is distinct from counselors, managers 
or supervisors and medical personnel. 
1 CTN is a partnership between NIDA researchers 
and community treatment providers to deliver new 
evidence-based treatments to a broader population of 
patients and to conduct multi-site clinical trials to 
determine the effectiveness of new therapies in 
diverse settings. 

* Including the use of buprenorphine, methadone, 
naltrexone, disulfiram, motivational enhancement 
therapy and voucher-based motivational incentives. 



§ See Chapter IX for a detailed discussion of the 
addiction-related credentialing requirements for 
health professionals. 

Most of the research related to the training of 
health professionals in addiction-related services 
focuses on tobacco cessation rather than interventions 
for addiction involving alcohol and other drugs. 
' ' e.g., The Substance Abuse and Mental Health 
Services Administration (SAMHSA) produces the 
National Registry of Evidence-Based Programs and 
Practices (NREPP), an online searchable database of 
evidence-based interventions for mental health and 
addiction prevention and treatment. 



-216- 



These factors, however, are not sufficient to 
justify the lack of medical attention to a disease 
affecting 1 6 percent of the population. 

Physicians. Poor training in the care of patients 
with addiction relates to low confidence among 
physicians in their ability or competence to treat 
such patients, negative attitudes toward patients 
with addiction, pessimism about the 
effectiveness of treatment and low rates of 
implementation of evidence-based practices 
related to screening, brief interventions and 
treatment. 185 



Only a small proportion of primary care 
physicians feel "very prepared" to detect 
particular types of risky use (alcohol- 19.9 
percent; illicit drugs- 16.9 percent; prescription 
drugs— 30.2 percent), which is in stark contrast 
to the much higher percentages of physicians 
who report feeling "very prepared" to identify 
hypertension (82.8 percent), diabetes (82.3 
percent) and depression (44.1 percent). 188 A 
state-based 2006 survey of primary care 
physicians found that the vast majority (88 
percent) screen for diabetes in adults with risk 
factors such as obesity, hypertension and a 
family history of diabetes. 189 

A 2004 survey showed that less than one third of 
certain medical professionals— registered nurses, 
dentists, psychiatrists and emergency medicine 
physicians— had received training in smoking 
cessation. 190 Another national study found that 
only half of psychiatry residency programs offer 



training in tobacco cessation, even though a 
state -based survey found that 94 percent of 
psychiatry residents would be interested in 
receiving available training. 192 A study of 
fourth-year medical students in New York City 
found that the majority (85 percent) did not 
know of local smoking cessation programs to 
which to refer patients. 193 And a national survey 
of directors and assistant directors of U.S. 
medical school obstetrics/gynecology training 
programs found that only nine percent reported 
offering students at least 1 5 minutes of time 
dedicated to improving students' tobacco 
cessation skills and only one-third (32.9 percent) 
reported that their programs taught students both 
how to intervene with patients who smoke and 
how to refer them for follow-up. 194 

Medical curricula, by providing insufficient 
information about recent advances in the 
neurological science of addiction, perpetuate 
misconceptions about the disease of addiction 
and inhibit the acceptance of biological models 
to explain the disease. 195 

Inadequate training with regard to tobacco, 
alcohol and other drug use also derives from 
limited exposure to role models in the field who 
have knowledge about these issues. 196 
Curriculum time and the number of faculty with 
expertise in addiction education pale in 
comparison to curriculum time and the number 
of faculty with expertise in education for health 
conditions with similar prevalence rates as 
addiction, such as cancer and heart disease. 197 



More than 20 years ago, the subspecialty of 
addiction psychiatry officially was 
established, 199 yet there often are more addiction 



Physicians can be the first line of defense 
against risky substance use and addiction, but 
they need the right tools and resources} 9,6 

-Nora D. Volkow, MD 
Director 

National Institute on Drug Abuse 

Most doctors do not look at addiction as part of 
their job. They may assess, but they don 't 
intervene. 1 * 1 

—Brian Hurley 
Chair 

Physicians-in-training Committee 
American Society of Addiction Medicine 



As medical students, many of us are perplexed by 
the lack of a formal standard of care regarding 
addiction. The sad thing is, many of my fellow 
students and I feel that too many of our attending 
physicians have not demonstrated to us that they 
believe that addiction can and should be 
addressed and that attitude affects patient care 
for the worse.™ 

— Kimberly Fitzgerald 
Fourth-year medical student 



-217- 



psychiatry residency positions available than 
there is demand for them. Although a survey of 
psychiatry residents found that most had positive 
attitudes towards addiction psychiatry, few 
residents believed that addiction psychiatrists 
were well paid and less than half (45 percent) 
believed a career in addiction psychiatry would 
be satisfying. 200 

The lack of physician training in addiction and 
its treatment has very real effects on patient 
care. For example, overwhelming evidence has 
proven that smoking cessation interventions are 
clinically effective and cost effective and that a 
patient's chances of quitting smoking are nearly 
doubled if a health professional advises him or 
her to quit. 201 Yet many medical schools do not 
require clinical training in smoking cessation. 202 



Other Health Professionals. Doctoral-level 
clinical psychologists are highly trained in 
psychosocial therapies, many of which can be 
applied effectively to addressing addiction in the 
significant proportion of their patient population 
that has co-occurring addiction and mental 
health disorders. 204 Yet because few 
psychologists receive adequate training in 
screening and intervention for risky substance 
users and in diagnosing, treating or referring 
patients with addiction, some fail to identify 
risky use or addiction or lack confidence in their 



ability to provide psychosocial therapies. For 
example, one study found that 17.1 percent of 
clinical psychologists reported that a barrier to 
providing smoking cessation counseling was 
their "lack of training in tobacco cessation 
skills." Other reported barriers also were related 
to a lack of knowledge about the disease: that 
smoking was "not the client's presenting 
problem" (57. 1 percent); that smoking cessation 
is not "a priority for my patients" (28.7 percent); 
"it may interfere with therapy goals" (2 1 .2 
percent); and "smoking patients are not 
interested in smoking cessation counseling" 
(19.8 percent). 206 

Dental professionals also receive inadequate 
training in caring for patients with risky 
substance use and addiction, 207 despite 
significant evidence of the important role they 
can play in screening, intervention and referral 
to treatment. 208 There are no national standards 
for tobacco cessation education in U.S. dental 
schools and the ability to provide tobacco 
cessation services is not considered a clinical 
competency. 209 Only about half of dental 
schools and dental hygienist programs* have 
tobacco cessation clinical activities integrated in 
their student clinics. 210 This is despite the fact 
that dental professionals are highly receptive to 
receiving substance-related training 211 and that 
appropriate training early in a clinician's career 
increases the likelihood that such interventions 
will be adopted and implemented in practice. 212 

Nurses constitute the largest group of health 
care professionals 213 with extensive patient 
contact; therefore, they are ideally situated to 
perform patient education, screening and brief 
intervention services. 214 Yet, nurses are not 
adequately prepared to perform these services, 
particularly tobacco cessation for which 
research indicates they can be particularly 
effective. 215 Barriers to the implementation of 
smoking interventions include a reported lack of 
motivation, self- efficacy, institutional support, 
time and training. 216 Nursing school curricula 
have little tobacco control content; there is a 
lack of tested curricula, nurse educators are not 



Forty-seven percent of dental schools and 55 
percent of dental hygienist programs. 



There are trained clinicians who do not fully 
understand the nature of addiction. 

I am amazed at how many if not most medical 
professionals have no understanding and little 
education on the subject. 

My relapse was in part due to ignorance in the 
medical profession and lack of medical 
addiction understanding during a life- 
threatening illness. 

...I escaped the clutches of doctors and 
psychiatrists with their prescription pads and 
rotten advice due to lack of understanding, due 
to lack of education.™ 

-Respondents to CAS A Columbia's 
Survey of Individuals in Long-Term Recovery 



-218- 



trained in it and it is considered to be a low 
priority in already overloaded curricula. 217 

Although pharmacists who engage in tobacco 
cessation interventions are effective in providing 
those services, 218 and despite the important role 
pharmacists can play in preventing the misuse of 
controlled prescription drugs, 219 most are not 
well trained to perform these functions, have 
little confidence to do so and believe that most 
patients are not interested in having them 

220 

intervene. 

A study in California found that the majority of 
pharmacists (88 percent) indicated that they 
would be interested in receiving specialized 
training in tobacco cessation counseling but 
fewer than eight percent had received any formal 
training. 221 A study of pharmacists in Florida 
found that 29.2 percent reported that they 
received no addiction-related education in 
pharmacy school and 53.7 percent reported that 
they had never referred a patient to addiction 

222 

treatment. 

Inadequate Use and Development of 
Pharmaceutical Treatments for Addiction 

The underutilization of pharmaceutical therapies 
in addiction treatment is another example of the 
disconnect between addiction treatment services 
and medical care. Many addiction treatment 
providers are unable to prescribe pharmaceutical 
therapies and medical professionals who could 
prescribe such therapies fail to address 
addiction. A related problem is that some 
medical professionals appear to have a 
disproportionate concern about the safety risks 
of addiction medications relative to medications 
aimed at treating other medical conditions. For 
example, although side effects for some 
addiction medications have been noted and 
safety concerns raised-particularly with regard 
to smoking cessation treatments, 223 side effects 
exist for many medications aimed at treating 
other health conditions and typically are 
acknowledged as an acceptable risk of treatment. 

Even when utilizing pharmaceutical treatments, 
medical professionals often fail to prescribe 
them at therapeutic doses. For example, 



methadone, which is used in treatment for 
addiction involving opioids, often is not 
prescribed as clinically recommended, 
undermining its effectiveness. 224 Specifically, 
although it is well understood that dosages 
between 60- 1 00 mg per day promote retention in 
treatment and reduction of opioid use, 225 34 
percent of patients are given doses of less than 
60 mg per day and 1 7 percent are given doses of 
less than 40 mg per day.* 226 Treatment 
programs more likely to give suboptimal doses 
of methadone include those with directors who 
take a 12-step approach to addiction 

227 

treatment. 



Furthermore, despite the potentially vast market 
for pharmaceutical treatments for addiction, the 
pharmaceutical industry has not made 
substantial investments in the development of 
new and effective addiction treatment 
medications. 231 One of the most significant 
contributing factors to the increased medical 
treatment of mental health disorders, such as 
depression and anxiety, in the past two decades 
has been the development and marketing of 
pharmaceutical treatments for these 
conditions. 232 However in recent years, the 
pharmaceutical industry has cut back 
dramatically on investments in the development 
of new pharmaceutical therapies for these and 
other mental health conditions. 233 The large 
profits that pharmaceutical companies were able 
to accrue from medications that were modified 



Although initial methadone treatment begins at 
dosages under 40 mg/day, the amount is increased 
gradually until cravings disappear. 



The Institute of Medicine and the Office of 
National Drug Control Policy (ONDCP) have 
recommended that treatment for addiction 
involving opioids be integrated into mainstream 
medical practice to improve availability and 
quality. 228 New York City has been a leader in 
this area with its Methadone Medical 
Maintenance program established more than 25 
years ago, 229 yet only 56 percent of need for 
methadone treatment in New York City was met 
in 2009; 230 inadequate training of providers may 
have restricted its expansion and integration 
with mainstream medical care. 



-219- 



versions of drugs already approved by the Food 
and Drug Administration meant that investments 
in innovative new medications were limited. 
Coupled with the rising cost of research and 
development, the fact that pharmaceutical 
companies face dramatic losses once the patents 
on many of their largest money-making drugs 
expire makes the current climate for the 
development of new innovative medications 
quite unfavorable. 234 

This is particularly unfortunate since recent 
advances in addiction science have highlighted 
specific neurotransmitter receptors and 
transporters that underlie addiction and that are 
promising targets for the development of 
medications to prevent and treat addiction. 235 

Aside from economic concerns, other factors 
inhibiting investments in new pharmaceutical 
interventions for addiction include an 
underestimation of the market for addiction 
treatment medications (i.e., the size of the 
population with addiction), the belief that the 
majority of those with addiction lack health 
insurance and the ability to pay for medications, 
and the long-standing stigma associated with the 
use of illegal substances and the disease of 
addiction. 236 



Translating the rapidly-evolving science of 
addiction into science-based treatments will 
require dramatic changes in incentives for the 
pharmaceutical industry to invest in innovative 
medications, increased public understanding that 
addiction is a treatable disease, and increased 
involvement of the health care system in its 
prevention and treatment. 



Inadequate Quality Assurance 

Addiction treatment providers do not speak with 
clarity or consistency about what the goals of 
treatment are, what counts as quality treatment, 
how performance and outcomes should be 
measured and what practices should be 
implemented to improve treatment and achieve 
measurable outcomes.* 239 And because 
addiction treatment for the most part is not 
integrated into mainstream health care, quality 
assurance standards and efforts to improve such 
standards in mainstream medicine largely do not 
apply to addiction treatment. 240 For example, 
organizations like the Council on Graduate 
Medical Education and the National Advisory 
Council on Nurse Education and Practice are 
public-private partnerships with Congressional 
mandates to provide sustained assessment of the 
needs of the medical and nursing fields. 241 
However, these organizations do not appear to 
address addiction treatment and comparable 
organizations for addiction treatment do not 
exist. 

Efforts to assure quality treatment within the 
mainstream medical system for patients with 
addiction are not typically adhered to. For 
example, as far back as 1979, the American 
Medical Association (AMA) adopted as policy 
the AMA Guidelines for Physician Involvement 
in the Care of Sub stance- Abusing Patients, 
which states that every physician must assume 
clinical responsibility for the diagnosis and 
referral of patients with addiction and explicates 
the particular competencies needed to fulfill that 
responsibility. Other similar efforts followed, 
with a national conference sponsored by the 
Office of National Drug Control Policy, the 
Leadership Conference on Medical Education in 
Substance Abuse, in 2004. Despite these and 
other efforts by government and professional 
organizations to put forth guidelines and 
principles aimed at ensuring proper training in 
risky substance use and addiction, physicians 
continue to be insufficiently equipped to address 
the needs of their substance-involved patients. 242 



See Chapter IX. 



For the most part, SUDs [substance use 
disorders] have not been high priority targets 
for the pharmaceutical industry. Even for 
smoking cessation, which offers a huge 
potential market, investments are negligible 
compared with the costs associated with 
developing medications to treat the 

237 

consequences of smoking. 

-Volkow & Skolnick, 2012 



-220- 



Efforts to assure quality treatment for addiction 
have proven highly fallible, with many barriers 
standing in the way of adequate performance 
and outcome measurement, including limited 
consensus regarding core quality standards and 
measures, inadequately developed measures and 
improvement mechanisms, and inadequate 
infrastructure and technical capacity. 243 

Further, the way in which addiction treatment is 
evaluated differs considerably from the 
evaluation of the effectiveness of treatment for 
other health conditions like diabetes, 
hypertension and asthma. Specifically, 
evaluations of the effectiveness of treatment of 
chronic diseases typically are conducted while 
the patient continues to receive treatment, since 
the treatment is considered critical to managing 
the disease. In the case of chronic addiction, 
however, evaluations of treatment effectiveness 
usually are conducted after the treatment has 
been withdrawn. 244 In other words, we use an 
acute care model to evaluate treatments for a 
chronic condition. 

Furthermore, because treatment facilities in 
some states cannot be licensed to provide both 
mental health and addiction treatment services, 
the mental health and addiction treatment 
systems are divided further. Given the large 
number of patients who suffer from co-occurring 
addiction and psychiatric disorders, the inability 
to treat both conditions concurrently within the 
same program is a significant barrier to 
providing quality care; it reduces the diagnosis 
and treatment of co-occurring conditions, 
impedes coordination of care, and increases the 
number of transfers which disrupts treatment. 245 

Lack of Consensus Regarding the Main Goals 
of Treatment. The primary goals of medical 
care are the prevention, diagnosis and treatment 
of illness, injury and disease, and the consequent 
relief of pain and suffering. 246 The picture is not 
as clear in addiction treatment: there is little 
agreement among addiction treatment providers 
about what the goals of treatment are or should 
be and whether successful treatment is defined 
by abstinence, a reduction in clinical symptoms 
or a reduction in negative health and social 
consequences. 247 Goals are not defined as 



improving health and function or disease 
stabilization as they are with other health 
conditions. Such inconsistency in goals makes 
measuring and assessing the effectiveness of 
treatment very difficult. 

CASA Columbia's survey of members of key 
treatment provider associations found that the 
majority (78.5 percent) "strongly agree" that 
improvements in functioning (e.g., employment, 
education, parenting, family stability, crime and 
recidivism, health, happiness, citizenship) is an 
important goal of addiction treatment; about half 
(52.5 percent) "strongly agree" that complete 
abstinence is an important goal; 44.0 percent 
"strongly agree" that remission of clinical 
symptoms is an important goal; and 43.8 percent 
"strongly agree" that reduced substance use is an 
important goal. Nearly half (45.1 percent) of 
respondents "strongly agree" that the patient 
should be allowed to set the goal that is right for 
him or her. 248 

Respondents to CASA Columbia's survey of 
treatment program directors and staff providers 
in New York State were more uniform in their 
support of complete abstinence as the main 
treatment goal for someone with addiction 
involving nicotine, alcohol or other drugs. 249 
(Table 10.2) 



See Appendix F. 

-221- 



Table 10.2 

New York State Addiction Treatment 
Providers' Opinions of the Main Goal of 
Treatment, by Substance 





Program 
Directors 


Staff 
Providers 


Tobacco 






Complete abstinence 


49.4 


48.2 


Reduced use 


10.8 


21.3 


Fewer negative consequences 


4.8 


11.3 


Goal set by patient 


41.0 


41.1 


Other goal 


3.6 


6.4 


Alcohol 






Complete abstinence 


61.4 


70.2 


Reduced use 


3.6 


9.2 


Fewer negative consequences 


10.8 


9.2 


Goal set by patient 


25.3 


22.0 


Other goal 


2.4 


3.5 


Other Drugs 






Complete abstinence 


66.3 


65.2 


Reduced use 


8.4 


9.2 


Fewer negative consequences 


13.3 


9.9 


Goal set by patient 


30.1 


26.2 


Other goal 


3.6 


5.7 



Source: CASA Columbia Survey of New York State 
Addiction Treatment Providers, 2009. 



Inadequate Performance and Outcome 
Measurement. Government and private funders 
and insurance companies increasingly are 
pressing addiction treatment programs to 
demonstrate the effectiveness of their programs 
and services. 250 However, most programs do not 
measure performance or treatment outcomes or 
have reliable evaluation data to demonstrate the 
efficacy of their services. 251 There is no 
national, unified body that sets standards for 
addiction treatment. 252 

CASA Columbia's survey of treatment program 
directors in New York State found that, when 
asked about the three main ways that their 
program evaluates how well it is doing, the most 
common response offered was "program 
completion rates" (68.7 percent); the next most 
common response was "random client 
feedback/testimonials" (54.2 percent). Neither 
of these measures adequately reflects treatment 



quality or effectiveness. Long-term follow up of 
patients is not typical, as only 34.9 percent of 
program directors reported following patients for 
more than six months after treatment exit to 
assess how well their patients were faring. 253 
Further complicating the measurement of 
outcomes is the failure to understand that 
addiction in many cases is a chronic disease that 
requires management over time. 



The effectiveness of addiction treatment is 
evaluated based on perverted measures of 
success... you'd never judge the benefits of an 
antihypertensive medication AFTER the 
medication had been stopped. 15 * 

-Michael M. Miller, MD 
Past President 
American Society of Addiction Medicine 



Most addiction treatment programs lack 
resources to develop and implement effective 
measurement systems. 255 Integrating addiction 
treatment into mainstream health care, however, 
would permit the performance and outcome 
measures and standards that have been well 
established for the treatment of other health 
conditions to be applied to addiction treatment 
as well. 

Inadequate Insurance Coverage 

In spite of recent expansions in coverage for 
intervention and addiction treatment through 
health care parity laws and the Affordable Care 
Act, insurance coverage for addiction and 
related services remains severely limited 
compared with coverage for other health 
conditions.* 256 This lack of insurance coverage 
for effective— and cost-effective— intervention 
and addiction treatment services provides a 
further barrier to increasing the attention of 
health care professionals to this disease. The 
end result is that millions of Americans are 
denied treatment, health care costs continue to 
rise as do social consequences and costs, and 
taxpayers foot the bill. 257 



See Chapter VIII. 



-222- 



No Overarching Organizing Body for 
Addiction Science and Treatment 

Unlike other major health conditions, there is no 
highly credible and unifying organization, 
within or outside of the National Institutes of 
Health (NIH), which sets standards and 
advocates for addiction prevention and 
treatment, including all manifestations of 
addiction. 

A key mission of the National Cancer Institute is 
to conduct and support "research, training, 
health information dissemination and other 
programs with respect to the cause, diagnosis, 
prevention and treatment of cancer, 
rehabilitation from cancer, and the continuing 
care of cancer patients and the families of cancer 
patients." 258 Likewise, according to the 
American Heart Association's description of its 
organization, "we fund innovative research, fight 
for stronger public health policies and provide 
lifesaving tools and information to prevent and 
treat these diseases." 259 

Although there are federal institutes and 
organizations dedicated to substance use and 
addiction, including the National Institute on 
Drug Abuse (NIDA), the National Institute on 
Alcohol Abuse and Alcoholism (NIAAA) and 
the Substance Abuse and Mental Health 
Services Administration (SAMHSA) as well as 
other organizations and institutes for which 
substance use and addiction are part of their 
focus,* there is no unified body that promotes 
research, public awareness and prevention and 
treatment quality for the disease of addiction. 
The result is a disjointed array of programs and 
efforts that often have quite different 
perspectives and approaches to addressing the 
issues surrounding substance use and addiction, 
which further contributes to the segmented view 
of addiction as multiple substance- and 
behavior-specific problems, rather than a single 
disease with different manifestations. 



Such as the National Cancer Institute (NCI), 
primarily in relation to smoking, the National 
Institute of Mental Health (NIMH) and the Centers 
for Disease Control and Prevention (CDC). 



A recent plan by the NIH would combine public 
health initiatives related to substance use and 
all addiction-related research within the NIH 
into a new institute focused on substance use 
and addiction. 260 This proposal is controversial 
with regard to how the merger will affect the 
funding and research portfolios not only of 
NIDA and NIAAA but also of other NIH 
institutes with interests that involve substance 
use and addiction (e.g., those that address 
cancer, HIV, prenatal care, birth defects, obesity, 
pain control). 261 Its strength is a clear and long- 
overdue recognition of the nature of the disease 
of addiction and the importance of addressing it 
in a unified way. 

Efforts to Integrate Substance Use 
Prevention and Treatment into 
Mainstream Medicine 

Recent efforts aimed at improving the 
prevention of risky substance use and the 
treatment of addiction have concentrated on the 
application of quality improvement and quality 
assurance measures such as those that have 
gained traction in mainstream health care 
practice: 

• Developing, disseminating and promoting 
evidence-based practices; 262 

• Improving the treatment provider workforce 
through enhanced education and training; 263 

• Improving performance measures; 264 

• Shifting evaluation efforts from a focus on 
performance-based measures that document 
the process of service delivery to a focus on 
patient outcomes, and rewarding those 
programs that demonstrate positive patient 
outcomes; 265 and 

• Using electronic health records and other 
forms of health information technology to 
track and monitor patients and help improve 
the coordination and delivery of care. 266 



-223- 



Many of these efforts, however, have been 
aimed at shoring up and maintaining a separate 
system of addiction treatment outside of 
mainstream health care practice. Although these 
are steps in the right direction, the research 
documented in this report demonstrates clearly 
that the current treatment infrastructure is 
riddled with barriers to closing the vast gap 
between research evidence and practice. 267 As 
such, modifications to the existing system 
simply will not suffice to make significant, 
meaningful and lasting improvements in how 
risky substance use and addiction are addressed 
in the United States. 

What is required is an integration of screening 
and intervention for risky substance use and 
treatment and management of addiction into 
mainstream health care, assuring that addiction 
treatment is managed by trained medical 
professionals and supported by an array of 
highly-trained clinical mental health 
professionals and other providers of essential 
support and auxiliary services. 268 Such 
integrated care leads to improved patient 
outcomes and significantly-reduced medical 
costs. 269 

Several recent developments have begun to 
make significant strides in this direction: 

• Efforts to expand insurance coverage for 
screening and brief interventions in primary 
care settings, to offer equitable coverage for 
addiction treatment services and to ensure 
accountability by establishing quality 
benchmarks in patient care as a condition for 



coverage. 



270 



Efforts by professional societies and 
associations to professionalize addiction 
treatment, have the medical field respond to 
risky substance use as a public health 
problem and addiction as a medical 
condition, and integrate care for risky 
substance use and addiction into medical 
practice. Notable examples include: 

> The American Society of Addiction 
Medicine (ASAM) which is seeking to 
improve the quality of care for risky 



substance use and addiction by: 
educating physicians and other health 
professionals about these issues; 
supporting research and prevention 
efforts; advocating for state and federal 
policies that would expand access to 
treatment; and working to establish 
addiction medicine as a recognized 
medical specialty. 271 

> The American Board of Addiction 
Medicine (ABAM), which was founded 
in 2007 with the encouragement and 
assistance of ASAM, is working toward 
the goal of establishing addiction 
medicine as a medical specialty 
recognized by the American Board of 
Medical Specialties (ABMS). ABAM's 
sister organization, the ABAM 
Foundation, began accrediting one- or 
two-year fellowship training programs- 
"secondary residencies"— in addiction 
medicine open to physicians completing 
training in any field certified by the 
ABMS member boards. Such 
programs have the ability to train the 
physician experts needed to meet the 
demand within health care teams at all 
locations where regular medical care is 
received-from hospitals to community 
clinics. The ABAM Foundation also is 
working toward having its fellowship 
training programs accredited by the 
Accreditation Counsel for Graduate 
Medical Education (ACGME). 272 
NIAAA and NIDA recently awarded 
grants to SUNY Buffalo and to Boston 
University Medical Center to help 
support this effort. 273 

> The American Society of Health- 
Systems Pharmacists, a member of the 
National Pharmacy Partnership for 
Tobacco Cessation, which has created a 
resource center to provide pharmacists 
with tobacco cessation information and 
tools to help patients stop smoking. 274 



The ABAM Foundation to date has accredited 10 
addiction medicine training programs across the 
country, with more programs under development. 



-224- 



• Efforts by government agencies to promote 
physician education and training in 
addiction science and addiction treatment 
and upgrade health care professionals' skills 
through the development and dissemination 
of screening tools and evidence-based 
clinical guidelines. 275 Notable examples 
include: 

> The National Institute on Drug Abuse's 
NIDAMED, a physician outreach 
initiative aimed at encouraging doctors 
to screen patients for risky substance 
use, including tobacco, alcohol and 
other drugs. NIDAMED offers free 
screening tools and prevention and 
treatment research and information that 
physicians can share with their patients. 
It also offers curriculum resources to 
provide scientifically accurate 
information to medical students, 
residents and faculty about substance 
use, addiction and its consequences. 276 

> The Substance Abuse and Mental Health 
Services Administration's SBIRT* 
Medical Residency Program, which 
seeks to develop and implement training 
programs for medical residents in 
evidence-based screening, brief 
intervention, brief treatment and referral 
to specialty treatment for risky 
substance use and addiction involving 
alcohol and other drugs, and to promote 
more broadly the adoption of these 
practices in the medical field. 277 

> The Health Resources and Services 
Administration's Project 
MAINSTREAM, which provides 
resources for educating a broad range of 
health care professionals ' in screening, 
brief intervention, referral to treatment, 



Screening, Brief Intervention, Referral and 
Treatment. 

f Including audiologists, dentists, dieticians, nurse 
midwives, nurse practitioners, nurses, occupational 
therapists, pharmacists, physical therapists, physician 
assistants, physicians, psychologists, public health 
professionals, social workers and speech pathologists. 



identifying and assisting children of 
parents with addiction and helping 
communities implement effective 
prevention programs related to addiction 
involving all substances. 278 

• Smaller-scale efforts to provide brief 
training to health professionals 1 ' in addiction 
science in order to improve the attitudes, 
proficiency and practices of all health 
professionals 279 -not just those who choose 
to specialize in addiction medicine or 
addiction psychiatry. Such brief trainings 
have proven effective in improving health 
professionals' knowledge, attitudes, 
confidence, motivation and practices with 
regard to providing smoking cessation 
services; 280 conducting screening and brief 
interventions for risky alcohol use in 
emergency departments 281 and for risky 
alcohol and other drug use in primary care 
facilities; 282 and for prescribing 
pharmaceutical medications such as 
methadone and buprenorphine for patients 
with addiction involving opioids. 283 

• The emergence of Patient-Centered Medical 
Homes 284 -in which a team of health 
professionals provides comprehensive and 
continuous medical care-is proving to be a 
strong model for addiction treatment to be 
integrated into the primary medical care 
system. 285 Recent research within the 
Medicaid and Veterans Health 
Administration systems demonstrates the 
success of this approach 286 and the potential 
to incorporate addiction care into this 
integrated system. 

• Efforts by quality assurance organizations to 
encourage services that address risky 
substance use and addiction within 
mainstream health care. For example, in 
2012, the Joint Commission announced new, 
voluntary measures for hospitals that choose 
to provide screening, brief intervention and 
referral to treatment for tobacco, alcohol and 



1 Including but not limited to physicians, physician 
assistants, nurses, nurse practitioners, dental 
professionals, pharmacists, social workers. 



-225- 



other drug use. The performance 
measurement sets related to alcohol and 
other drugs include screening, brief 
interventions, treatment, discharge planning 
and follow up. 287 The specifications for the 
tobacco cessation performance measures 
include screening all patients to identify 
tobacco users, providing or offering 
evidence-based counseling and medications 
for smokers during hospitalization and upon 
discharge, and assessing tobacco use 30 
days post-discharge. 288 Hospitals are 
required to choose four out of 14 possible 
core performance measurement sets, with no 
requirements about which sets must be 
chosen. 289 For each core performance 
measurement set that the hospital chooses, 
the hospital is held accountable for 
collecting data and measuring performance 
related to the activities associated with the 
set. However, other sets of measures that 
hospitals may choose to be held accountable 
for include those that they already perform 
routinely, limiting the reach of this 
promising development which would require 
more effort and resources than most other 

290 

measurement sets. 



Our perspective is that, although tactically 
impressive, the [Joint Commission's] 
measure set [regarding tobacco screening and 
cessation services] is strategically flawed 
because its adoption is optional. 291 

-Fiore, M.C., Goplerud, E., & 
Schroeder, S. A. (2012) 

If the Joint Commission would require 
hospitals to report their outcomes on SBIRT, 
it could do more to medicalize how we deal 
with risky substance use than all the urging 
and pleading we 've undertaken for the past 
25 to 30 years. 292 

-Larry M. Gentilello, MD 
Trauma Services 
Kaiser Permanente Hospital 
Sacramento, CA 



-226- 



Chapter XI 

Recommendations and Next Steps 



As this report has documented, addiction is a 
complex brain disease and the risky use of 
addictive substances is a significant public 
health problem. Together they result in untold 
human suffering and cost taxpayers billions of 
dollars each year. Effective, evidence-based 
interventions and treatment options exist that 
can and should be delivered through the health 
care system. A substantial body of research 
demonstrates that providing effective 
prevention, intervention, treatment and disease 
management services yields improvements in 
health and considerable reductions in costs to 
government and taxpayers; research also 
suggests that providing these services does not 
result in significant increases in insurance costs. 
In the face of these facts, it is unethical, 
inhumane and cost prohibitive to continue to 
deny effective care and treatment for the 40.3 
million Americans with this disease or to fail to 
screen and intervene with the 80.4 million who 
engage in risky use of addictive substances. 

No one group or sector alone can realize the 
changes required in health care practice, 
government regulation and spending, insurance 
coverage, and public understanding to bring 
addiction prevention and treatment and 
reductions in risky substance use in line with the 
standard of care for other public health and 
medical conditions. Concerted action is required 
on the part of physicians and other medical and 
health professionals, policy makers, insurers and 
the general public. 

This is not an unprecedented challenge. There 
have been many examples where health care 
practice has lagged behind the science. Only 
recently, depression was considered a character 
flaw before the brain science was understood 
and HIV/AIDS was considered a moral scourge 
before it was seen as a virus that can be 
prevented, treated, managed and perhaps cured. 
Likewise, addiction has been seen for too long 



-227- 



as a character flaw and a moral failing rather 
than a preventable and treatable disease. 

It is past time for health care practice to catch up 
with the science. Efforts already underway to 
close this gap must be expanded and accelerated. 
Toward this end, CASA Columbia makes the 
following recommendations: 

Reform Health Care Practice 

Incorporate Screening and Intervention for 
Risky Substance Use, and Diagnosis, 
Treatment and Disease Management for 
Addiction into Routine Medical Practice 

As essential components of routine medical care 
practice, all physicians and other medical 
professionals should provide their patients with: 

• Routine screening for all forms 

of risky substance use—including tobacco, 
alcohol, illicit drugs and controlled 
prescription drugs-at initial visit to a 
primary care or specialty care physician and 
routinely thereafter, and upon entry into a 
hospital, emergency department, trauma 
center or clinic; 

• Brief interventions as needed; 

• Comprehensive assessment to determine 
disease stage and severity as well as the 
presence of co-occurring health conditions 
and special population needs; 

• Patient stabilization (e.g., detoxification), 
when necessary, as a precursor to treatment; 

• Development of a tailored treatment plan 
that includes: 

> Acute treatment via evidence-based 
psychosocial and/or pharmaceutical 
interventions; 

> Chronic disease management, as 
needed; 



> Connection to support and auxiliary 
services-including legal, educational, 
employment, housing and family 
supports, nutrition and exercise 
counseling, and mutual support 
programs; and 

> Referral to physicians trained in 
addiction medicine or addiction 
psychiatry for specialty care as needed. 

Evidence-based screening can be conducted by a 
broad-range of licensed providers with general 
training in addiction and specific training in how 
to conduct such screens and what to do with 
patients who screen positive. Brief interventions 
can be provided by health professionals- 
licensed graduate-level medical or mental health 
clinicians-trained in addiction care. 

Treatment and disease management services can 
be provided through a multi-disciplinary team of 
appropriately trained and credentialed health 
professionals managed by a physician: 

• Comprehensive assessment, diagnosis, 
stabilization, acute treatment and disease 
management must be performed or managed 
by physicians in collaboration with a team 
of licensed graduate- level medical or mental 
health clinicians trained in addiction care; 

• Case management can be provided by 
licensed physician assistants, nurses and 
nurse practitioners and mental health 
clinicians trained in addiction care; 

• Auxiliary services can be provided by a 
range of professional and paraprofessional 
personnel working within the treatment and 
disease management plan; 

• Peer support, often an important component 
of the larger treatment plan, can be provided 
by those who have learned to manage the 
disease. 



-228- 



All Medical Schools and Residency 
Training Programs Should Educate and 
Train Physicians to Address Risky 
Substance Use and Addiction 

All physicians should be educated and trained in 
the origins of risky substance use and addiction; 
prevention, intervention, treatment and 
management options; co-occurring conditions; 
and special population and specialty-care needs, 
including: 

• What constitutes risky substance use, the 
harms of such use to health and safety and 
the importance of reducing risky use; 

• How to screen for risky substance use and 
conduct brief interventions when indicated; 

• The causes and correlates of addiction; 

• How to diagnose addiction; evaluate disease 
stage, severity, co-occurring disorders and 
needs of special populations; and develop a 
treatment and disease management plan 
including appropriate support services; 

• How to collaborate with and manage a 
multidisciplinary team of providers; 

• How to provide or supervise psychosocial 
and pharmaceutical treatments for addiction 
and disease management; 

• How to arrange for and connect patients 
with auxiliary support services; and 

• How to determine the need for specialty care 
and connect patients with such care. 

These core clinical competencies should be 
required components of all medical school 
curricula, medical residency training programs, 
medical licensing exams, board certification 
exams and continuing medical education (CME) 
requirements, including maintenance of 
certification programs. 



Require Non-Physician Health 
Professionals to be Educated and Trained 
to Address Risky Substance Use and 
Addiction 

Develop core clinical competencies in 
addressing risky substance use and preventing 
and treating addiction for each type of non- 
physician health professional including 
physician assistants, nurses and nurse 
practitioners, dentists, pharmacists and graduate- 
level clinical mental health professionals 
(psychologists, social workers, counselors). 
These competencies should include: 

• What constitutes risky substance use, the 
harms of such use to health and safety and 
the importance of reducing risky use; 

• How to screen for risky substance use and 
conduct brief interventions when indicated; 

• The causes and correlates of addiction; 

• Available psychosocial and pharmaceutical 
treatments for addiction and disease 
management; 

• How to arrange for and connect patients 
with auxiliary support services; and 

• How to determine the need for specialty care 
and connect patients with such care. 

Assure that these core clinical competencies and 
specialized training are required components of 
all professional health care program curricula, 
graduate fellowship training programs, 
professional licensing exams and continuing 
education (CE) requirements. 

For non-physician health professionals involved 
in the provision of addiction care, core 
competencies also should include how to work 
in concert with a patient's physician and other 
health care providers to screen for risky 
substance use; provide brief interventions; 
diagnose addiction; evaluate disease stage, 
severity and co-occurring disorders; and develop 



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a treatment plan, including appropriate support 
services. 

Require all non-physician health professionals 
providing psychosocial addiction treatment 
services to have graduate-level clinical training 
in delivering these services. 

Require that all pharmaceutical treatments for 
addiction be provided only by a physician or in 
accordance with a treatment plan managed by a 
physician. 

Develop Improved Screening and 
Assessment Instruments 

Screening instruments should be adjusted or 
developed to coincide with appropriate 
definitions of risky substance use, and 
assessment instruments should be adjusted or 
developed to mirror diagnostic criteria for 
addiction. Both screening and assessment 
instruments should address all types of addictive 
substances. 

Establish National Accreditation Standards 
for All Addiction Treatment Facilities and 
Programs that Reflect Evidence-Based 
Care 

As a condition of accreditation, accrediting 
organizations should stipulate requirements for 
all facilities and programs providing addiction 
treatment with regard to professional staffing, 
intervention and treatment services and quality 
assurance: 

• Professional Staffing. All facilities and 
programs providing addiction treatment 
should be required to have a full-time 
certified addiction physician specialist on 
staff to serve as medical director, oversee 
patient care and be responsible for all 
treatment services. All individual providers 
of patient care in these facilities and 
programs should be required to be licensed 
in their field of practice and demonstrate 
mastery of the core clinical competencies. 
Professionals who are in the process of 



becoming licensed must be supervised at all 
times by a licensed professional. 

• Intervention and Treatment Services. All 
facilities and programs providing addiction 
treatment should be required to provide 
comprehensive assessment and evidence- 
based treatment for addiction involving all 
substances that is tailored to the stage and 
severity of the disease, co-occurring 
conditions and patient characteristics. 

• Quality Assurance. All facilities and 
programs providing addiction treatment 
should be required to collect and report 
comprehensive quality assessment data, 
including process and outcome 
measurements related to screening, 
intervention, treatment and disease 
management, in accordance with established 
guidelines developed in collaboration with 
the American Board of Addiction Medicine. 

Standardize Language Used to Describe 
the Full Spectrum of Substance Use and 
Addiction 

Recognize addiction as a medical disease and 
standardize the language related to the spectrum 
of substance use severity in current and 
forthcoming diagnostic instruments. Develop a 
classification system based both on observable 
behavior and neurobiological measures that 
underlie different manifestations of addiction 
and related conditions which currently are 
classified and addressed as distinct conditions. 



Currently, the provision of such services frequently 
is optional. For example, the Joint Commission 
currently has voluntary performance measures for 
hospitals that choose to provide these addiction- 
related services. However, hospitals are required to 
choose four out of 14 possible core performance 
measurements sets and may completely avoid those 
related to addiction care (see Chapter X). 



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Use the Leverage of Public Policy to 
Speed Reform in Health Care 
Practice 

Condition Grants and Contracts for 
Addiction Services on the Provision of 
Quality Care 

Federal, state and local governments should 
require—as a condition of receipt of public 
funds— that grants, contracts and non-insurance 
reimbursement for addiction treatment services: 

• Utilize evidence-based prevention and 
treatment approaches, including 
pharmaceutical therapies (provided or 
managed by a physician demonstrating the 
core competencies of addiction medicine or 
addiction psychiatry) and psychosocial 
therapies (provided by medical professionals 
or graduate-level clinical mental health 
professionals trained and licensed in the core 
competencies of addiction treatment), as 
indicated; 

• Involve other health professionals, 
individuals providing auxiliary services and 
those providing peer support, working in a 
multidisciplinary team; and 

• Generate positive and measurable long-term 
patient outcomes. 

Educate Non-Health Professionals about 
Risky Substance Use and Addiction 

Require that the topic of risky substance use and 
addiction be included in the education and 
training of government-funded professionals 
who do not provide direct addiction-related 
services but who come into contact with 
significant numbers of individuals who engage 
in risky substance use or who may have 
addiction. These include, but are not limited to 
law enforcement and other criminal justice 
personnel, legal staff, child welfare and other 
social service workers and educators. Substance 
use- and addiction-related content should 
include: 



• What constitutes risky substance use, the 
harms of such use to health and safety and 
the importance of reducing risky use; 

• The nature of the disease of addiction and 
the medical and other health services needed 
to address it; and 

• How to identify signs and symptoms of 
risky use and addiction and connect those 
with such signs and symptoms to 
professional services. 

Identify Patients at Risk in Government 
Programs and Services where Costs of 
Risky Use and Addiction Are High 

Federal, state and local governments should 
require that routine screening and brief 
interventions be provided by trained 
professionals in all educational, mental health, 
developmental disabilities, child welfare, 
housing, juvenile justice and adult corrections 
services that receive public funding; and that 
patients who screen positive for risky use or a 
potential diagnosis of addiction be connected 
with a trained health professional for 
intervention, diagnosis, treatment and disease 
management. 

Develop Tools to Improve Service Quality 

Federal and state governments in collaboration 
with professional associations, accrediting 
organizations and other non-profit organizations 
focusing on health care quality— such as the 
Washington Circle,* the National Committee for 



* The Washington Circle is a group of national 
experts in addiction-related policy, research and 
performance management who seek to improve the 
quality and effectiveness of prevention and treatment 
services through the use of performance 
measurement systems. 



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Quality Assurance (NCQA) and the National 
Quality Forum (NQF) t -should develop and 
disseminate evidence-based tools, practice 
guidelines and performance measures oriented 
toward patient outcomes to improve the quality 
of addiction care (involving all substances) and 
require their implementation as a condition of 
continued licensure and/or accreditation. 

License Addiction Treatment Facilities as 
Health Care Providers 

Federal, state and local governments should 
subject all addiction treatment facilities and 
programs to the same mandatory licensing 
processes as other health care facilities. 

Require Adherence to National 
Accreditation Standards that Reflect 
Evidence-Based Care 

As a condition of licensure, federal, state and 
local governments should stipulate that all 
facilities and programs providing addiction 
treatment adhere to established national 
minimum standards for accreditation (see 
recommendation under Reform Health Care 
Practice above). 

Require that All Insurers Provide Coverage 
for Comprehensive Addiction Care 

• Require that all health insurers— public and 
private -provide coverage for all insured 
individuals for patient education, screening 
and intervention for risky substance use and 
treatment and management of addiction 
(involving all substances associated with 



addiction) consistent with standards of 
medical practice, eliminating exemptions. 

• As a condition of reimbursement, public 
payers and private insurance companies 
should be mandated to require that all 
addiction interventions and treatment be 
directly provided, supervised or managed by 
trained medical professionals. 

• Public payers and private health insurance 
companies should use all available tools- 
including quality assurance measurements, 
pay-for-performance contracting and other 
incentives— to encourage participating 
providers and facilities to adopt evidence- 
based practices, institute quality- 
improvement measures and assess patient 
outcomes. 

• Eliminate the Uniform Accident and 
Sickness Policy Provision Law (UPPL) 
which bars insurance coverage for injuries 
sustained by a person who was under the 
influence of alcohol or other drugs at the 
time of the injury; this law impedes 
appropriate medical care. 

Expand the Addiction Medicine Workforce 

Accelerate the work begun by the American 
Board of Addiction Medicine Foundation to 
develop residency training programs in addiction 
medicine and secure residency accreditation 
from the Accreditation Council for Graduate 
Medical Education (ACGME). Pursue and gain 
recognition of addiction medicine by the 
American Board of Medical Specialties 
(ABMS). Support the efforts of ACGME- 
accredited addiction psychiatry residencies to 
increase the number of enrolled residents. 
Through these actions, assure that addiction 
medicine training programs are available to 
physicians, that training opportunities within 
addiction psychiatry are expanded, and that such 
specialty care will be available in every hospital 
throughout the country and through every health 
care system, including the Federally Qualified 



* NCQA focuses on improving health care quality 
and manages the Healthcare Effectiveness Data and 
Information Set (HEDIS), a standardized 
performance measurement tool used by the majority 
of health insurance plans in the United States to 
measure performance on important dimensions of 
care and service. 

' NQF is a public-private partnership that establishes 
priorities for quality improvement and endorses 
standards for evidence-based addiction practice and 
measuring performance. 

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Health Centers (FQHCs),* the Department of 
Veterans Affairs (VA) and the Indian Health 
Service (IHS): 

• Allocate a designated portion of the 
federally-funded (primarily through 
Medicare) medical residency training 
positions to residency training in the 
specialty of addiction medicine, including 
addiction psychiatry. 

• Allocate residency training slots through the 
VA and the IHS to addiction medicine to 
help ensure the availability of specialty care 
for veterans and Native Americans. 

• Provide additional resources as needed to 
immediately increase the training and 
availability of addiction medicine specialists 
to meet the need nationwide. 



Implement a National Public Health 
Campaign 

Implement a nationwide public health campaign 
through the Centers for Disease Control and 
Prevention (CDC), the Food and Drug 
Administration (FDA) and other federal 
agencies charged with protecting the public 
health to educate the public about all forms of 
risky substance use and addiction, specifically 
with regard to: 

• What constitutes risky substance use and the 
nature of the disease of addiction; 

• Risk factors for each as well as their health, 
social, safety and economic consequences; 

• The importance of preventing all forms of 
substance use among adolescents to protect 
their immediate health and safety and 
because of the link between early use and 
later addiction; 

• How to spot signs of risk in individuals of 
all ages; and 

• When to seek help and where to turn for 
effective intervention and care. 

Invest in Research and Data Collection to 
Improve and Track Progress in Addiction 
Prevention, Treatment and Disease 
Management 

Invest in research designed to: 



/ think we have to be mindful that creating a 
subspecialty is not a substitute for physicians 
and other providers developing greater 
knowledge and skill in the addiction field. There 
are too many patients. We 're not going to be 
able to train enough specialists to treat all those 
folks. The general medicine field needs to accept 
that these are legitimate medical conditions for 
which they should take responsibility. 1 

--Peter D. Friedmann, MD, MPH 
Professor of Medicine 
Professor of Health Services, Policy and Practice 

Brown University 

We want addiction prevention, screening, 
intervention, and treatment to become routine 
aspects of medical care, available virtually any 
place health care is provided. 2 

-Kevin B. Kunz, MD 
Former President 
American Board of Addiction Medicine 

(ABAM) 



• Develop reliable and valid screening and 
assessment tools that address risky 
substance use and addiction involving all 
substances and addictive behaviors, and that 
can be tailored to special populations. 

• Identify bio-markers associated with disease 
stages. 



• Provide evidence from clinical trials to 
further the understanding of: 

* FQHCs serve populations such as the homeless, 
those residing in public housing and migrant workers. 



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> The efficacy of stabilization, acute 
treatment (psychosocial and 
pharmaceutical interventions) and 
disease management for addiction 
involving all substances; and 

> The effectiveness of these approaches in 
various real-world settings, including 
among people of different ages, 
races/ethnicities, in the justice 
population and among other special 
populations. 

Determine best practices in addiction care 
and how best to move evidence-based 
interventions into practice. 

Evaluate the effectiveness of current and 
newly-developed interventions and 
treatments against models of best practice, 
as well as the effectiveness of various types 
of support services as adjuncts to clinical 
treatment. 

Better understand the shared genetic, 
biological and environmental mechanisms 
underlying different manifestations of 
addiction. 

Develop the technological infrastructure 
(including electronic health records) 
necessary to collect and disseminate 
performance and outcomes measures for 
research and evaluation. 

Develop practice support tools such as those 
for electronic screening and brief 
intervention (e.g., via the Internet, smart 
phones and other electronic devices), based 
on findings from implementation research, 
that facilitate integration of addiction care 
into medical practice. 

Provide incentives to the pharmaceutical 
industry to develop and market new and 
effective pharmaceutical interventions for 
addiction treatment. 

Collect data in areas that currently are 
devoid of evidence, such as: 

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> The screening and intervention services 
gap— data collected on a unified sample 
regarding both the prevalence of risky 
substance use and the prevalence of 
receipt of specific screening and 
intervention services. 

> Treatment of addiction involving 
nicotine alone and in combination with 
other substances and behaviors- 
prevalence, types of treatments, 
expenditures and outcomes. 

• Find a cure for the disease of addiction. 

Implement the National Institutes of 
Health's (NIH) Recommendation to Create 
a Single Institute Addressing Substance 
Use and Addiction 

Create a unified national institute focused on 
substance use and addiction, recognizing the 
overarching disease of addiction rather than 
continuing the focus on different manifestations 
of substance use and the disease-tobacco, 
alcohol, other drug use— and including the risky 
use of all addictive substances. Include in the 
research portfolio addiction involving behaviors 
other than substance use, and focus on the 
causes, correlates, consequences, interventions, 
policies and possible cures for all manifestations 
of the disease. The portfolio of the institute also 
should include health conditions resulting from 
risky use and addiction (such as birth defects, 
cardiac complications, Hepatitis C, substance- 
related HIV-AIDS) and other conditions which 
increase the risk of developing addiction (such 
as post-traumatic stress disorder, traumatic brain 
injury and other mental health disorders). 



Appendix A 
Methodology 

CASA Columbia performed the following 
activities to present a comprehensive analysis of 
addiction and its treatment in the United States: 

• A thorough review of more than 7,000 
scientific articles, reports, books and other 
reference materials related to the science of 
addiction, the consequences of risky use and 
addiction, the prevention of risky use and 
treatment of addiction and barriers to 
improved care; 

• Secondary analyses of five national data 
sets; 

• Interviews with and suggestions from 1 76 
leading experts in a broad range of fields 
relevant to the report, including researchers, 
physicians and other health professionals, 
other treatment providers, policymakers and 
members of professional associations, 
advocacy organizations, health insurers, 
pharmaceutical companies and organizations 
of people with the disease of addiction. 
Whereas the majority of these experts 
provided their thoughts in the context of an 
open-ended interview guide designed by 
CASA Columbia to explore key themes 
related to this project (see Appendix B for a 
list of the questions asked and of the 
individuals who were interviewed), some 
provided advice, suggestions and feedback 
about specific content to be included in this 
report; 

• Focus groups and a national general 
population survey assessing the attitudes and 
beliefs of 1,303 adults with regard to 
addiction and its treatment: the National 
Addiction Belief and Attitude Survey 
(NABAS) (see Appendix C for the survey 
instrument); 



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• Two statewide surveys of addiction 
treatment providers in New York State: one 
of 83 program directors and one of 141 staff 
treatment providers (see Appendices D and 
E for survey instruments); 

• A national panel of treatment providers and 
an online survey of 1,142 members of 
professional associations involved in 
addiction care (see Appendix F for a list of 
panel members and for the survey 
instrument); 

• An online survey of 360 individuals with a 
history of addiction who are managing the 
disease (i.e., in "long-term recovery") (see 
Appendix G for the survey instrument); 

• An in-depth analysis of state, federal and 
professional associations' licensing and 
certification requirements for individual 
treatment providers and addiction treatment 
facilities and programs, as well as 
accreditation requirements for facilities and 
programs; and 

• A case study of addiction treatment in New 
York State and New York City that drew 
from the research described above and the 
findings of which are incorporated into the 
report where relevant. 

Literature Review 

CASA Columbia research staff identified and 
reviewed more than 7,000 scientific articles, 
reports, books and other reference materials. 

Analysis of National Data Sets 

CASA Columbia's Substance Abuse Data 
Analysis Center (SADAC SM ) conducted 
extensive analyses of the following five national 
data sets: 

• National Survey on Drug Use and Health 
(NSDUH); 

• Treatment Episode Data Set (TEDS); 



• National Survey of Substance Abuse 
Treatment Services (N-SSATS); 

• Drug Abuse Warning Network (DAWN); 
and 

• Fatality Analysis Reporting System (FARS). 
National Survey on Drug Use and Health 

The National Survey on Drug Use and Health 
(NSDUH), administered by the U.S. Department 
of Health and Human Services' Substance 
Abuse and Mental Health Services 
Administration (SAMHSA), is a cross-sectional 
national survey of approximately 70,000 (per 
year) randomly selected non-institutionalized 
individuals ages 12 and older in the United 
States. Because of changes made in survey 
methodology, time series data are available only 
from 2002. 

The NSDUH is known to underestimate 
considerably the rate of substance use, 
particularly among young people, because it is 
administered in the home where a parent or 
other adult is present, increasing the risk that 
respondents will under-report substance use and 
other high-risk or illegal activities. 1 The 
NSDUH also does not include high-risk 
institutionalized populations, such as prison 
inmates, hospital patients, patients in residential 
addiction treatment and others who cannot be 
reached in a home (e.g., the homeless), who tend 
to engage in substance use at higher rates than 
non- institutionalized populations. 2 

For each type of addictive substance, the 
NSDUH provides data on lifetime use, current 
use, frequency patterns, past-month diagnosis of 
nicotine addiction and past-year diagnosis of 
alcohol or other drug addiction. Data related to 
determining whether a respondent met clinical 
criteria for a past-year addiction diagnosis 
involving alcohol, controlled prescription drugs 
or illicit drugs correspond to the diagnostic 
criteria for alcohol or other drug abuse or 
dependence presented in the Diagnostic and 
Statistical Manual of Mental Disorders, 4th 
edition (DSM-IV). 3 Data related to determining 



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whether a respondent met clinical criteria for a 
past-month addiction diagnosis involving 
nicotine are based on the Nicotine Dependence 
Syndrome Scale (NDSS). 4 The NDSS measures 
five dimensions of nicotine dependence based 
on symptoms and characteristics outlined in the 
DSM-IV. 5 The NDSS was designed for adult 
smokers; although an adolescent version of the 
NDSS has been developed, 6 the NSDUH uses 
the adult version. 

CASA Columbia analyzed NSDUH data on 
individuals ages 12 and older living in U.S. 
households to examine the risky use of tobacco, 
alcohol, illicit drugs and controlled prescription 
drugs; addiction involving these substances; the 
prevalence of co-occurring health conditions; 
and rates of risky use and addiction among those 
who had past-year involvement in the justice 
system. 

Treatment Episode Data Set 

The Treatment Episode Data Set (TEDS), 
sponsored by the U.S. Department of Health and 
Human Services' Substance Abuse and Mental 
Health Services Administration (SAMHSA), 
provides information on the demographic and 
substance use characteristics of the 
approximately 2.0 million annual admissions in 
2009 to addiction treatment programs in 
facilities that report to individual state 
administrative data systems. TEDS does not 
include all treatment admissions. Rather, it 
includes admissions to facilities that are licensed 
or certified by the designated state substance 
abuse agency to provide treatment (or are 
administratively tracked by the agency for other 
reasons). Facilities reporting TEDS data 
generally are those that receive state alcohol 
and/or other drug agency funds (including 
Federal Block Grant funds) for the provision of 
addiction treatment services; states report on all 
admissions to programs receiving public funds 
and on admissions to private facilities for which 
they have data. TEDS is an admissions-based 
system and TEDS admissions do not represent 
individuals. Thus, an individual admitted to 
treatment twice within a calendar year would be 
counted as two admissions. 



The scope of admissions included in TEDS is 
affected by differences in state reporting 
practices, varying definitions of treatment 
admission, availability of public funds and 
public funding constraints. For example, 
treatment programs based in the criminal justice 
system may or may not be administered through 
the state substance abuse agency. 
Detoxification facilities, which can generate 
large numbers of admissions, are not uniformly 
considered treatment facilities and are not 
uniformly reported by all states. 

Facilities operated by federal agencies (e.g., the 
Bureau of Prisons, the Department of Defense 
and the Department of Veterans Affairs) 
generally do not report TEDS data to the state 
substance abuse agency, although some 
facilities operated by the Indian Health Service 
are included. Hospital-based addiction 
treatment facilities frequently are not licensed 
through the state substance abuse agency and do 
not report TEDS data. Correctional facilities 
(state prisons and local jails) are monitored by 
the state substance abuse agency and report 
TEDS data in some states but not in others. 

In addition to admissions data, TEDS has a 
separate data set for patient discharges from 
addiction treatment. The discharge variables 
include treatment completion, length of stay, 
substances of addiction, type of services offered, 
demographic information and other data about 
those ages 12 and older who were discharged 
from addiction treatment facilities in 2008. 

CASA Columbia analyzed TEDS admissions 
data for the years 2002 through 2009 to 
characterize the sources of referral, types of 
treatment and primary substances involved in 
the addiction of individuals ages 1 1 and older, as 
well as TEDS discharge data from 2008 to 
assess the completion and dropout rates for 
treatment admissions. (Note that after 2009, 
TEDS only reported admissions for those ages 
12 and older). 



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National Survey of Substance Abuse 
Treatment Services 

The National Survey of Substance Abuse 
Treatment Services (N-SSATS), sponsored by 
the U.S. Department of Health and Human 
Services' Substance Abuse and Mental Health 
Services Administration (SAMHSA), is 
designed to collect information from all 
treatment facilities in the United States, both 
public and private, that provide addiction 
treatment. N-SSATS data allows examination of 
the composition of the U.S. addiction treatment 
delivery system. CASA Columbia analyzed this 
data to investigate variations in care by 
providers, the patterns of accreditation and 
licensing of facilities by various characteristics 
and the availability of services to specialized 
populations (e.g., adolescents, women, patients 
with co-occurring disorders). 

Drug Abuse Warning Network 

The Drug Abuse Warning Network (DAWN) 
public health surveillance system, conducted by 
the U.S. Department of Health and Human 
Services' Substance Abuse and Mental Health 
Services Administration (SAMHSA), monitors 
substance-related emergency department (ED) 
visits from a national sample of general, non- 
federal hospitals that operate 24-hour EDs, with 
oversampling of hospitals in selected 
metropolitan areas. In participating hospitals, 
ED medical records are reviewed retrospectively 
to identify visits related to recent substance use. 
Illicit drugs, prescription and over-the-counter 
pharmaceuticals, dietary supplements and non- 
pharmaceutical inhalants are included in the 
analysis. Alcohol, when present in combination 
with another drug, is included as well. When 
alcohol is the only substance implicated in a 
visit, it is included only for patients younger 
than age 2 1 . 

CASA Columbia analyzed DAWN data to 
examine the number of ED visits involving 
alcohol and other drugs (excluding nicotine). 



Fatality Analysis Reporting System 

The National Center for Statistics and Analysis 
(NCSA) of the National Highway Traffic Safety 
Administration (NHTSA) conducts the Fatality 
Analysis Reporting System (FARS), a 
nationwide census providing yearly data 
regarding fatal injuries from motor vehicle 
traffic crashes. FARS contains data derived 
from a census of fatal traffic crashes within the 
50 States, the District of Columbia and Puerto 
Rico. The results of alcohol and other drug tests 
are recorded, as well as police officers' 
determination of alcohol and/or other drug 
involvement. The FARS database contains 
descriptions-in standardized formats-of each 
fatal crash reported. 

CASA Columbia analyzed FARS data to 
examine the role of alcohol and other drug use in 
fatal motor vehicle crashes. 

Key Informants 

CASA Columbia staff reached out to leading 
experts in a broad range of fields relevant to the 
study. Responses from key informants* were 
solicited and received between July 2007 and 
May 2012. Comments were received from 176 
individuals (109 by phone, 64 via e-mail and 
three in person). Informants were identified 
through a literature review, past research, 
referrals from CASA Columbia's National 
Advisory Commission which was convened for 
this study, and through a snowball sample where 
respondents recommended other qualified 
interviewees. (See Appendix B for the interview 
guide and list of participants.) 

Where informants were amenable, an interview 
guide was used. The methodology and 
interview protocol were approved by CASA 
Columbia's Institutional Review Board (IRB). 



* The term "key informant" is used in reference to the 
list of individuals specifically contacted and asked to 
answer questions identified in Appendix B or to 
provide comments and suggestions on the scope of 
the study, key issues to be addressed and suggestions 
for recommendations. The full list of Key Informants 
is included in Appendix B. 



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In other cases, informants made specific 
comments related to the scope of the study, key 
issues to be addressed and suggestions for 
recommendations. The responses were analyzed 
by CASA Columbia staff to identify key themes, 
provide illustrative quotes and inform 
subsequent research efforts. 

The National Addiction Belief and 
Attitude Survey (NAB AS) 

CASA Columbia designed and developed a 
focus group protocol and a survey to assess the 
addiction-related attitudes and beliefs of a 
nationally-representative sample of adults. 
CASA Columbia staff, in collaboration with 
Peter D. Hart Research Associates, a survey 
research firm, developed the focus group 
discussion guide and survey instruments. Peter 
D. Hart Research Associates arranged for and 
moderated the focus groups and fielded the 
survey. 

The recruiting and screening materials, consent 
protocol, focus group discussion guides, 
methodology and survey instrument were 
approved by CASA Columbia's IRB. 

Focus Groups 

Focus groups were conducted at research 
facilities in Atlanta, GA and Philadelphia, PA. 
The first set of focus groups took place in 
Atlanta, GA on May 13, 2008. The second set 
of groups was held in Philadelphia, PA on May 
20, 2008. In each city, one group was composed 
of respondents without a college education and 
the other was made up of respondents who had 
completed college. 

All participants were administered a screening 
questionnaire as part of the recruitment process. 
Because it was considered unlikely that we 
would be able to recruit a representative sample 
of those managing their disease to participate in 
the focus groups, and inclusion of just several 
such people in the group might bias the 



No qualitative differences were found in the 
responses of these two groups of participants. 



discussion, individuals with addiction who were 
currently managing the disease were excluded 
from participation. Efforts also were made to 
split the groups as evenly as possible between 
participants who had immediate family members 
with a history of addiction and those who did 
not. Participants also had to be between the ages 
of 25 and 70. A relatively even balance of men 
and women was sought in each group. 
Participants were paid $90 for participating in 
the focus group session. 

The National Survey 

Using results of the focus groups, gaps identified 
in the literature and the goals of this study as a 
guide, a pretest survey was developed by CASA 
Columbia staff with input from Peter D. Hart 
Research Associates. This pretest survey was 
administered and then modified and the final 
questionnaire was administered by means of a 
telephone survey. (See Appendix C for the 
survey instrument and response frequencies.) 

Peter D. Hart Research Associates staff 
completed interviews with 1,303 adults by 
telephone between October 21, 2008 and 
November 3, 2008. 

Of the respondents, 196 reported personal 
experience with addiction, while 887 
respondents reported having family members or 
close friends with a history of addiction. 

The margins of error for the telephone survey 
were: 

• +/- 2.7 percent among all respondents; 

• +/- 7.0 percent among those with personal 
experience with addiction; and 

• +/- 3.3 percent among those with family 
members or close friends with a history of 
addiction. 

Telephone numbers in the sample were called up 
to four times. A total of 3,663 households 
answered the phone and attempts were made to 



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complete an interview with an adult member in 
each of those households: 

• Refusal Rate Prior to Obtaining Informed 
Consent: Thirty-seven percent (1,364 
respondents) broke off before the 
interviewer could obtain informed consent. 
The remaining 63 percent (2,299 
respondents) stayed on the line and 
answered the informed consent question. 

• Refusal Rate of Informed Consent: Sixty- 
nine percent (1,595 respondents) agreed to 
the informed consent question. The 
remaining 3 1 percent (704 respondents) 
refused at the point of informed consent and 
terminated the survey. 

• Breakoff Rate: Once the survey questions 
began, 82 percent (1,303 respondents) 
completed the interview. The remaining 1 8 
percent (292 respondents) terminated the 
survey before it was completed. 

Overall, 35.6 percent (1303/3663) of those we 
attempted to contact completed the survey. 

Surveys of Addiction Treatment 
Directors and Staff Providers in 
New York State 

CASA Columbia collaborated with the Survey 
Research Laboratory (SRL) of the University of 
Illinois at Chicago to obtain a representative 
sample of treatment facilities and programs (and 
their directors and staff) in New York State. 
The goal of the surveys was to explore the types 
of treatment services provided in addiction 
treatment facilities and programs in New York, 
how performance and outcomes are assessed and 
the attitudes and beliefs of treatment providers 
concerning addiction and its treatment. (See 
Appendix D for the program directors' survey 
instrument and response frequencies and 
Appendix E for the staff providers' survey 
instrument and response frequencies.) 
The target population included addiction 
treatment providers, including Department of 
Veterans Affairs (VA) facilities, located in New 
York State. Because the number of facilities 



that treated adolescents was too few for us to 
draw a representative sample across New York 
State given our limited resources, only adult- 
only treatment centers were eligible to 
participate in the survey. We received the initial 
sample frame from the New York State Office 
of Alcoholism and Substance Abuse Services 
(OASAS). The goal was to complete interviews 
with the director and two staff members at 75 
treatment facilities, for a total of 225 interviews 
(75 directors plus 150 staff members). We 
estimated that we would need to begin with a 
sample of 500 treatment facilities in order to 
obtain the target number of completed 
interviews. 

The methodology, recruiting and screening 
materials, consent protocols and survey 
instruments were approved by CASA 
Columbia's IRB. 

Between December 17, 2008 and February 27, 
2009, 83 facilities agreed to participate, resulting 
in interviews with 83 facility directors and 141 
staff treatment providers within the 83 facilities. 
The survey protocol utilized multiple data 
collection modalities including telephone, fax 
and the Internet. To construct the initial frame 
of 500 facilities, SRL staff telephoned facilities 
to ensure that they were still in business and still 
seeing patients/clients. Once a pool of more 
than 500 eligible facilities was created, we 
issued screening forms to the pool to assess 
which facilities would be willing to participate; 
224 of the 549 eligible facilities completed the 
screening instrument, resulting in a 40.8 percent 
screening response rate. Since our goal was 75 
completed facility surveys, we recruited in 
blocks of 20 from the 224 facilities that 
completed the screening instrument. We 
exceeded the goal, resulting in a completion 
rate of 15.1 percent (83/549) of eligible 
facilities, or 37.1 percent (83/224) of responding 
facilities. 

The simple margin of error (calculated without 
taking into account the complex sampling 
structure) was approximately +/- 10 percent for 
the director survey and approximately +/- 8 
percent for the staff provider survey. 



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National Panel of Treatment 
Providers and National Online 
Survey of Members of Professional 
Associations Involved in 
Addiction Care 

CASA Columbia convened a small, national 
panel of treatment providers. Panel members 
were asked to provide their perspectives on 
issues and barriers they faced in providing 
quality services and their recommendations for 
improvement in the treatment system. 
Organizations that assisted in identifying panel 
members included: NAADAC, the Association 
for Addiction Professionals;* the State 
Associations of Addiction Services (SAAS); the 
National Council for Community Behavioral 
Healthcare (National Council); the National 
Association of Addiction Treatment Providers 
(NAATP); and the American Society of 
Addiction Medicine (ASAM). Panel members 
are listed in Appendix F. 

This panel also assisted CASA Columbia in 
developing a brief, online national convenience 
survey of members of professional associations 
involved in addiction care to help understand 
their views of addiction treatment including: the 
relative importance of various components of 
the treatment process, the goals of treatment, the 
barriers to the implementation of high-quality 
treatment and recommendations for improving 
access to treatment and quality care. (See 
Appendix F for the survey instrument and 
response frequencies.) 

Eleven professional associations agreed to share 
the link to the survey either via a group e-mail, a 
posting on their Web site or in an association 
newsletter. The 1 1 associations were: The 
American Academy of Addiction Psychiatry 
(AAAP); the American Association for the 
Treatment of Opioid Dependence (AATOD); the 
American Psychological Association (APA); the 
American Society of Addiction Medicine 
(ASAM); the Association for the Treatment of 



Formerly named the National Association for 
Alcoholism and Drug Abuse Counselors 
(NAADAC). 



Tobacco Use and Dependence (ATTUD); 
NAADAC, the Association for Addiction 
Professionals; the National Association of 
Addiction Treatment Providers (NAATP); the 
National Association of County Behavioral 
Health and Developmental Disability Directors 
(NACBHDD); the National Council for 
Community Behavioral Healthcare (National 
Council); the State Associations of Addiction 
Services (SAAS); and Treatment Communities 
of America (TCA). f 

The methodology, recruiting and screening 
materials, consent protocol and survey 
instrument were approved by CASA Columbia's 
IRB. 

Between May 2007 and May 2008, 1,142 
members of the treatment provider associations 
completed the survey. The survey was 
anonymous. 

Online Survey of Individuals 
Managing Their Addiction 

CASA Columbia developed an online survey 
using a convenience sample of individuals who 
have been managing their addiction (i.e., "in 
recovery") to explore factors that have helped 
them manage the disease and challenges they 
have faced over the years in doing so. (See 
Appendix G for specific survey questions and 
response frequencies.) 

To qualify for participation, respondents had to 
be age 1 8 or older. 

The following agencies and organizations agreed 
either to send an e-mail blast with an embedded 
survey link to their members or to include the 
link in a newsletter or other material that would 
reach those in the recovery groups: Hazelden, 
Freedom Institute, Faces and Voices of 
Recovery, Betty Ford Center, National Council 
on Alcoholism and Drug Dependence, Inc. 
(NCADD), Treatment Communities of America 
(TCA), Alcoholism and Substance Abuse 



1 Formerly named Therapeutic Communities of 
America (TCA). 



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Providers of New York State, Inc. (ASAP) and 
an anonymous treatment program alumni group. 

The survey was anonymous; therefore, there is 
no way to determine with certainty if the 
responses provided by those who chose to 
respond are representative of the membership as 
a whole or of the broader group of individuals 
managing the disease of addiction ("in 
recovery"). 

The methodology, recruiting and screening 
materials, consent protocol and survey 
instrument were approved by CASA Columbia's 
IRB. 

Respondents self-defined as being in "long-term 
recovery" (i.e., not currently undergoing 
detoxification or acute treatment); 360 
respondents completed the survey. The average 
reported length of being "clean and sober" was 
10 or more years. The survey links were open 
from July 2007 to July 2008. 

Review of Licensing, Certification 
and Accreditation Requirements 
for Treatment Providers 

Between 2009 and 2012, CASA Columbia 
conducted online reviews and analyses of 
publicly available documents to develop a 
summary overview of the regulatory landscape 
related to government, professional association 
and other accrediting agency requirements 
related to the provision of addiction treatment 
services. In some cases where key information 
could not be identified or where requirements 
were unclear, we called or e-mailed the relevant 
state agency or organization for clarification. 
Because licensing and certification requirements 
are found in a wide variety of laws and 
regulations and can change on a state -by-state 
basis, findings from this review cannot be 
guaranteed to be complete and current. 



Using the Lexis/Nexis database to supplement 
information related to state laws and regulations 
available on the Internet. 



Individual Provider Licensing and 
Certification Requirements 

CASA Columbia reviewed publicly-available 
federal and state laws and regulations (in all 50 
states and the District of Columbia) and 
professional association Web sites, to determine 
the minimum education and training 
requirements to become licensed or certified in 
each of the following professions most likely to 
provide addiction treatment in the United States: 
physicians, physician assistants, nurses, 
psychologists, mental health counselors/ 
therapists, social workers, acupuncturists and 
addiction counselors. We collected data on state 
licensing requirements for each profession, 
including addiction-related requirements and 
voluntary certification requirements for 
addiction specialists in each profession. 

Addiction Facility/Program Licensing and 
Accreditation Requirements 

CASA Columbia reviewed publicly-available 
federal and state laws and regulations that 
govern addiction treatment facilities in all 50 
states and the District of Columbia. We also 
reviewed accreditation standards for addiction 
facilities and programs set forth in the 
Commission on Accreditation of Rehabilitation 
Facilities' (CARF) Behavioral Health Standards 
Manual and the Joint Commission's Standards 
for Behavioral Health Care. CARF and the Joint 
Commission are the two largest accreditors of 
addiction treatment programs. ' We collected 
data on requirements pertaining to staff 
composition and qualifications, provided 
services, quality assurance activities and the use 
of patient outcomes data. 

Case Study of Addiction Treatment 
in New York 

CASA Columbia conducted a case study of 
addiction treatment in New York State and New 
York City with support from the New York 
Community Trust. The goal of this work was to 
provide an in-depth look at one state/city parallel 



See Chapter IX. 



-242- 



with the objectives of the larger study. To 
conduct the case study, CASA Columbia staff 
drew from the research methods described 
above, to the extent that the findings pertained to 
New York, including, for example, a literature 
review focused on addiction treatment in New 
York; key informant interviews with experts 
from New York; the surveys of New York State 
addiction treatment directors and staff providers; 
the survey of individuals managing their 
addiction— 80 respondents were from New York 
and accessed through two New York-based 
organizations: New York Association of 
Alcoholism and Substance Abuse Providers, Inc. 
(ASAP) and National Council on Alcoholism 
and Drug Dependence, Inc. (NCADD); and the 
credentialing requirements for treatment 
providers in New York. Relevant findings from 
these analyses and illustrative quotes from key 
informants are incorporated into the report. 



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Appendix B 

Key Informant Interview Guide and List of Key Informants 



Name: 
Title: 

Organization: 
Interviewer: 
Interview Date: 

Q 1 How do you think the average person in the US today perceives (thinks about) substance abuse and 
addiction (e.g., physical health problem, mental health problem, behavioral problem, moral problem, 
social problem, criminal justice problem)? 

Q2 Do you think this perception has changed in the last 20 years? 

Q3 How do you perceive (think about) substance abuse and addiction (e.g., physical health problem, 
mental health problem, behavioral problem, moral problem, social problem, criminal justice problem)? 

Q4 Do you think addiction is a family disease? If so, do you think it requires some type of intervention or 
treatment for members other than the addict? Please explain. 

Q5 How easy is it, in your opinion, to get effective help for an addiction problem in America (or in NYC, 
for NYC Case Study key informants) today? 

Q6 When people are looking for help for an addiction problem, who do they usually turn to or where do 
they go and why? 

Q7 When someone gets help for an addiction problem, what type of help do they usually receive? 

Q8 How would you define treatment for substance abuse or addiction? 

Q9 What is your definition of effective treatment for substance abuse or addiction? 

Q10 What should the goals of treatment be (e.g., complete abstinence, reduction in use, reduction in 
harmful consequences; remission of DSM symptoms)? 

Q 1 1 Under what conditions does effective treatment of addiction require treatment of co-morbid 
psychiatric conditions? 

Q12 What do you think can be done to make treatment more science- or evidence-based? Is evidence 
from research findings accessible and understandable to providers, as well as to policymakers and 
advocacy groups? 

Q13 What is your assessment of the capacity of treatment programs in the U.S. (or in NYC, for NYC 
Case Study key informants) to deliver effective and appropriate treatment to those with substance use 
disorders? 

Q14 What do you think stands in the way of people getting quality, effective treatment and of providers 
offering quality, effective treatment? 



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Q 1 5 Do you think that most treatment providers are qualified to help individuals with substance abuse or 
addiction problems? Please explain. 

Q16 Do you think there should be minimum standards of knowledge, skills and/or training for an 
individual to provide treatment? If so, what are some examples or suggestions for those minimum 
standards? 

Q17 What do you think are three key things that would improve the quality of addiction treatment in 
America (or in NYC, for NYC Case Study key informants)? 

Q 1 8 Where do you think the substance use and addiction field will be in 20 years? Where would you like 
it to be? 

Q 1 9 Is there anything we have not asked you that you would like to discuss? 



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New York State- Specific Key Informants 



Barry, Justin, City wide Drug Court Coordinator, Criminal Court of the City of New York 
Carpenter-Palumbo, Karen M., Commissioner, New York State Office of Alcoholism and Substance 

Abuse Services - OASAS 
Conlon, Peggy, President and Chief Executive Officer, Advertising Council, Inc. 
Coppola, John, Executive Director, New York Association of Alcoholism and Substance Abuse 

Providers, Inc. (ASAP) 
Deitch, MD, David, Chief Clinical Officer, Phoenix House New York 
Donowitz, Stephen C, Director, Adolescent Services, Phoenix House New York 
Feinblatt, JD, John, Criminal Justice Coordinator, City of New York 

Galanter, MD, Marc, Professor, Department of Psychiatry and Director, Division of Alcohol and Drug 

Abuse, New York University 
Gebbie, PhD, RN, Kristine, Elizabeth Standish Gill Associate Professor of Nursing, Columbia University 

School of Nursing 

Gitlow, MD, MPH, MBA, Stuart, Executive Director, Annenberg Physician Training Program 
Gourevitch, MD, MPH, Marc N., Professor Medicine and Professor of Psychiatry, Director, Division of 

General Internal Medicine, Bellevue Primary Care Clinic 
Hawkins, PhD, Barry, Director, Chemical Dependency Services, Orange County Department of Mental 

Health 

Hogan, PhD, Michael F., Commissioner, New York State, Office of Mental Health 
Hynes, Charles, District Attorney, Kings County 

Johnson, MD, Brian, Director of Addiction Psychiatry and Associate Professor, State University of New 

York, Upstate Medical University 
Josepher, Howard, Co-Founder and Executive Director, Exponents 

Kellogg, PhD, Scott, Clinical Assistant Professor, Psychology, New York University, FAS Psychology 
Department 

Kistenmacher, PhD, Barbara, Director, Addictions Treatment, Bronx Lebanon 

Kleber, MD, Herbert D., Professor of Psychiatry and Director of the Division on Substance Abuse at the 
Columbia University College of Physicians and Surgeons and the New York State Psychiatric 
Institute, New York State Psychiatric Center 

Leary, Robyn, Executive Director, Recovery Network Foundation 

Levounis, MD, Petros, Director, Addiction Institute of New York 

Lindsey, Robert, President, National Council on Alcoholism and Drug Dependence 

Lopez, MD, Ralph I., Clinical Associate Professor of Pediatrics and Associate Attending Physician, Weill 
Cornell Medical Center 

McDonald, George T., Founder and President, The Doe Fund, Inc. 

Meitiner, Howard P., President and Chief Executive Officer, Phoenix House New York 

Nadelmann, Ethan, Executive Director, Drug Policy Alliance 

Newman, MD, MPH, Robert G., Director, The Baron Edmond de Rothschild Chemical Dependency 

Institute, Beth Israel Hospital Center 
Pantin, MSW, Debra, Vice President, Outpatient and Centralized Services, Palladia, Inc. 
Raine, Valerie, Director, Drug Court Programs, Center for Court Innovation 
Randolph, MD, Chris, Medical Director, Phoenix House New York 
Riddle, Kathleen A., President and Chief Executive Officer, Outreach Project 
Rosen, Paul, Staff Director, Senate Caucus on International Narcotics Control, Office of U.S. Senator 

Biden 



Titles and affiliations represent those at the time of Key Informant participation. 



-247- 



Rosenthal, MD, Richard N., Head, Public Policy Section, American Academy of Addiction Psychiatry, 
and Professor of Clinical Psychiatry and Chairman, Department of Psychiatry, St. Luke's Roosevelt 
Hospital Center 

Ross, MD, Stephen, Director, Substance Abuse Services, Bellevue Hospital Center and South Manhattan 
Healthcare Network 

Rotrosen, MD, John, Professor, Department of Psychiatry, New York University, School of Medicine 
Samuels, JD, Paul N., Director and President, Legal Action Center 

Savoy, LCSW, CASAC, Jeffrey R., Vice President and Director of Clinical Support Services, Odyssey 
House, Inc. 

Schwartz, MD, Bruce J., Director of Clinical Services for Substance Abuse, Montefiore Medical Center 
Sederer, MD, Lloyd I., Medical Director, New York State, Office of Mental Health 
Swanson, PhD, Arthur J., Program Director, University Behavioral Associates, Montefiore Medical 
Center 

Swern, Anne, District Attorney's Office, Kings County 

Travis, JD, Jeremy, President, John Jay College of Criminal Justice 

Wadalavage, Kevin, Vice President, Outreach Development Corporation 

Weinstein, MPH, Naomi, Director, Phoenix House Center on Addiction and the Family (COAF) 
Wilkens, PhD, Carrie, Clinical Director, Center for Motivation and Change 

General Study Key Informants 1 

Albanese, MD, FACP, FASAM, Anthony, Chief of Hepatology and Chemical Dependency, VA Northern 
California Healthcare System, Health Sciences Professor of Medicine & Psychiatry, UC Davis School 
of Medicine 

Allem, Johnny W., President and Chief Executive Officer, Johnson Institute 

Amico, MDiv, Joseph M., President, National Association of Lesbian and Gay Addiction Professionals 
Babor, PhD, MPH, Thomas F., Professor, Physicians Health Services Chair in Community Medicine and 

Public Health, Department of Community Medicine and Health Care, University of Connecticut 

Health Center 

Bart, MD, FACP, FASAM, Gavin, Director, Division of Addiction Medicine, Department of Medicine, 
Hennepin County Medical Center; Associate Professor of Medicine, University of Minnesota 

Baxter, Sr., MD, FASM, Louis E., Executive Medical Director, Professional Assistance Program of New 
Jersey 

Beauchemin, Patricia, Executive Director, Therapeutic Communities of America* 
Berger, PhD, Thomas J., National Chair, PTSD & Substance Abuse Committee 
Breyer, Ellen L., President and Chief Executive Officer, Hazelden Foundation 
Brown, PhD, Stephanie, Director, The Addictions Institute 

Callahan, DPA, James F., Executive Vice President, The American Board of Addiction Medicine, and 
The ABAM Foundation 

Carroll, PhD, Kathleen M., Professor of Psychiatry, Yale University, School of Medicine, Division of 
Substance Abuse 

Cimaglio, Barbara, Deputy Commissioner for Alcohol and Drug Abuse Programs, Vermont Department 
of Health 

Clark, MD, JD, MPH, H. Westley, Director, Center for Substance Abuse Treatment 
Cohen, Michael, Executive Director, Florida Lawyers Assistance Program 

Colston, MA, Stephenie W., Director, Substance Abuse Program, Florida Department of Children and 
Families 



Titles and affiliations represent those at the time of Key Informant participation. 
Currently named Treatment Communities of America (TCA). 



-248- 



Compton, MD, MPE, Wilson M., Director, National Institutes of Health, Division of Epidemiology, 

Services and Prevention Research 
Condon, PhD, Timothy P., Deputy Director, National Institute on Drug Abuse 

Covington, PhD, Stephanie, Director, Institute for Relational Development/The Center for Gender and 
Justice 

Cropper, Cabell C, Executive Director, National Criminal Justice Association 
Cundiff, MD, MPH, Dave, Secretary, American Association of Public Health Physicians 
Curie, Charles G., President, The Curie Group, LLC 

Dackis, MD, Charles A., Medical Director of Clinical Services, Department of Psychiatry, University of 

Pennsylvania Health System 
Daley, PhD, Dennis C, Professor of Psychiatry, Chief, Addiction Medicine Services, Principal 

Investigator, Appalachian Tri-State Node of the NIDA Clinical Trails Network, Western Psychiatric 

Institute and Clinic, University of Pittsburgh Medical Center 
D'Aunno, PhD, Thomas, Professor of Health Policy and Management, Mailman School of Public Health, 

Columbia University 
Davis, MD, Ronald M., President, American Medical Association 
Dawes, Jacqueline, Founder and Owner, Brookhaven Retreat 

Dean, Gen. Arthur T., Chairman and Chief Executive Officer, Community Anti-Drug Coalitions of 
America 

Delos Reyes, MD, Christina M., Assistant Professor of Psychiatry, Department of Psychiatry, School of 
Medicine, Case Western Reserve University; Director, Addiction Psychiatry Fellowship, University 
Hospitals Case Medical Center 

Dentzer, Susan, Health Correspondent and Head, Health Policy Unit, The News Hours with Jim Lehrer, 
PBS 

Duffy, MD, F. Daniel, Senior Advisor to the President, American Board of Internal Medicine 
Dukakis, JD, Michael S., Chair, Blueprint for the States, Join Together Policy Panel Members 
Durham, PhD, Thomas G., Executive Director, The Danya Institute 

Dyak, Marie, Executive Vice President, Program Services & Government Relations, Entertainment 
Industries Council 

Erickson, PhD, Carlton K., Director, Addiction Science Research and Education Center and 

Distinguished Professor of Pharmacology/Toxicology, University of Texas at Austin, College of 
Pharmacy 

Evans, Jr., PhD, Arthur C, Acting Commissioner, Department of Human Services, Pennsylvania 

Department of Behavioral Health/Mental Retardation Services 
Farabee, PhD, David, Research Psychologist at the University of California, Los Angeles and Director of 

the Integrated Substance Abuse Programs (ISAP) Juvenile Justice Research, UCLA Integrated 

Substance Abuse Programs 
Finney, John W., Director, HSR&D Center For Health Care Evaluation, VA Palo Alto Health Care 

System 

Flaherty, PhD, Michael T., Executive Director, IRETA - Institute for Research, Education and Training 
in Addiction 

French, PhD, Michael T., Professor of Health Economics and Director, Health Economics Research 

Group, University of Miami, Department of Sociology 
Galea, MD, DrPH, MPH, Sandro, Associate Professor, Department of Epidemiology, University of 

Michigan, School of Public Health 
Gallon, PhD, Steve, Director, Northwest Frontier ATTC, Department of Public Health and Preventive 

Medicine, Oregon Health & Science University 
Gertig, JD, June, Director, CSAT Recovery Community Services Program Technical Assistance Program, 

Health Systems Research, Inc. 
Glantz, PhD, Meyer D., Associate Director for Science, National Institute on Drug Abuse 



-249- 



Goplerud, Eric, Senior Vice President, Substance Abuse, Mental Health and Criminal Justice Studies, 

NORC at the University of Chicago 
Greer, Patricia M., President, National Association of Alcoholism and Drug Abuse Counselors 

(NAADAC) § 

Gustafson, PhD, David, Professor Emeritus, University of Wisconsin, Madison 

Guthrie, PhD, RN, FAAN, Barbara J., Associate Dean of Academic Affairs, Associate Professor School 

of Nursing, Yale University, School of Nursing 
Hajela, MD, MPH, Raju, President and Medical Director, Health Upwardly Mobile, Inc. (HUM); Region 

IX (International) Director, American Society of Addiction Medicine 
Hamburg, MD, David A., President Emeritus, Carnegie Corporation of New York; former President, 

American Association for the Advancement of Science and the Institute of Medicine, DeWitt Wallace 

Distinguished Scholar, Weill Cornell Medical College 
Hamilton, Nancy, Chief Executive Officer, Operation PAR 

Harwood, Henrick, Director of Research and Program Applications, National Association of State 

Alcohol and Drug Abuse Directors, Inc. 
Hatcher, EdD, Anne S., Director, Center for Addiction Studies, Metropolitan State College of Denver 
Higgins-Biddle, PhD, John C, Assistant Professor (Retired), University of Connecticut Health Center, 

Department of Community Medicine and Health Care 
Hill, MD, J. Edward, Immediate Past President, American Medical Association 
Hoffman, PhD, Norman G., President, Evince Clinical Assessments 

Howell, MD, FASAM, DFAPA, Elizabeth F., Associate Professor (Clinical), Department of Psychiatry, 

University of Utah School of Medicine 
Huddleston, III, C. West, Chief Executive Officer and Executive Director, National Association of Drug 

Court Professionals, National Drug Court Institute 
Humphreys, PhD, Keith N., Professor (Research) of Psychiatry and Behavioral Sciences; CHP/PCOR 

Associate, Stanford School of Medicine, Department of Psychiatry 
Hurley, MD, MBA, Brian, Chair, Physicians-In-Training Committee, American Society of Addiction 

Medicine, National Vice President, American Medical Student Association 
Jackson, MSW, Ron, Executive Director, Evergreen Treatment Services 

Janes, William H., Former Director, Florida Office of Drug Control, Office of the Governor, Florida 
Karlin, PhD, Barry W., Chairman and Chief Executive Officer, CRC Health Group 
Katz, MD, MS, Nathaniel, Founder, Analgesic Research 

Kosten, MD, Thomas R., Professor, Department of Neuroscience, Baylor College of Medicine 

Kosterman, PhD, Judi Marie, Senior Vice President, WestCare Foundation, Inc. 

Kressler, MA, Harry, Executive Director and Superintendent, Pima Prevention Partnership 

Kunz, MD, MPH, FASAM, Kevin, Director and Immediate Past President, American Board of Addiction 

Medicine and The ABAM Foundation 
Leary, William R., Executive Director, Louisiana Lawyers' Assistance Program 

Leshner, PhD, Alan I., Chief Executive Officer, American Association for the Advancement of Science 
Lewis, MD, David C, Professor Emeritus of Medicine and Community Health, Brown University 
Ling, MD, Walter, Professor of Psychiatry and Director, Integrated Substance Abuse Programs, 

Department of Psychiatry & Behavioral Sciences, David Geffen School of Medicine at UCLA 
Lundberg, MD, ScD, George D., Co-Chair, Board of Directors, PLNDP, PLNDP National Office, Center 

for Alcohol and Addiction Studies, Brown University 
Maine, PhD, Margo D., Co-Founder, Maine & Weinstein Specialty Group 
Malliarakis, Kate, President, KAM Associates 

Marlatt, PhD, G. Alan, Professor and Director, Addictive Behaviors Research Center, University of 

Washington, Department of Psychology 
Martin, MD, Judith, Medical Director, BAART Turk Street Clinic 



Currently named NAADAC, the Association for Addiction Professionals. 



-250- 



McAuliffe, PhD, William, Director, North Charles Research and Planning Group 

McCaffree, MD, Robert, Chief of Staff, VA Medical Center, Oklahoma City, OK 

McCaffrey, Gen. Barry R., Founder, BR McCaffrey Associates LLC 

McDonough, James, Secretary, Florida Department of Corrections 

McLellan, PhD, A. Thomas, Chief Executive Officer, Treatment Research Institute 

McMillen, LSAC, MPA, Shawn M., Executive Director, First Step House 

McVay, Doug A., Director of Research and Editor, Common Sense for Drug Policy 

Miller, MD, Michael M., Medical Director, Herrington Recovery Center, Rogers Memorial Hospital, 

Oconomowoc, WI; Past President, American Society of Addiction Medicine; Director, American 

Board of Addiction Medicine and The ABAM Foundation 
Miller, PhD, William R., Distinguished Professor of Psychology and Psychiatry, Center on Alcoholism, 

Substance Abuse and Addictions 
Mills, MBA, Penny S., Executive Vice President and Chief Executive Officer, American Society of 

Addiction Medicine 

Minkoff, MD, Kenneth, Clinical Assistant Professor of Psychiatry, Harvard University 
Molloy, JD, J. Paul, Chief Executive Officer, Oxford House 

Moore, EdD, Dennis C, Director, Substance Abuse Resources and Disability Issues and Professor, 

Department of Community Health, Boonshoft School of Medicine, Wright State University Building 

Moos, PhD, Rudolph, Professor, Department of Psychiatry and Behavioral Sciences, Stanford University 
School of Medicine 

Moyers, William Cope, Vice President, External Affairs, Hazelden Foundation 
Murphy, Steven W., Executive Director, The Right Step-San Antonio 
Newhouse, Eric, Project Editor, Great Falls Tribune 
Nicolaus, Martin, Chief Executive Officer, LifeRing Service Center 
Norman, Cathy, Prosecutor, Vermont Attorney General's Office 

O'Brien, MD, PhD, Charles P., Kenneth E. Appel Professor and Vice Chair of Psychiatry, University of 
Pennsylvania and Director of Research, MIRECC, Philadelphia Veterans Affairs Medical, Charles 
O'Brien Center for Addiction Treatment 
Powell, Richard, Director of Addiction and Violence Services, Vermont Department of Corrections 
Rawson, PhD, Richard, Associate Director, Professor-in-Residence, UCLA Integrated Substance Abuse 
Programs 

Ries, MD, Richard K, Professor of Psychiatry and Director, Addictions Division, University of 

Washington Department of Psychiatry 
Rivara, MD, Frederick P., Professor, Pediatrics and Adjunct Professor, Epidemiology 
Robinson, Stephen L., Government Relations Director, Veterans for America 
Rosen, Paul, Staff Director, Senate Caucus on International Narcotics Control, Senator Biden 
Rosenbloom, PhD, David, Professor, Boston University, Join Together 

Samet, MD, MA, MPH, Jeffrey H., Clinical Addiction Research and Education (CARE) Program, 

Professor of Medicine and Social and Behavioral Sciences, Boston University School of Medicine 
Satel, MD, Sally, Resident Scholar, American Enterprise Institute for Public Policy Research 
Schwarzlose, John T., President, Betty Ford Center 

Sindelar, PhD, Jody L., Professor and Head, Division of Health Policy and Administration, Yale 

University, School of Public Health 
Sloboda, PhD, Zili, Senior Research Associate, Institute for Health and Social Policy, University of 

Akron 

Snow, PhD, Diane, Clinical Professor and Director, Psychiatric Mental Health NP Program and Co- 
Director, Center for Psychopharmacology Education and Research, University of Texas, Arlington 
School of Nursing 

Starer, MD, FACOG, FASAM, Jacquelyn, Coordinator, CSAC Division of Opioid Dependent Pregnant 

Patients at Community Substance Abuse Centers 
Stitzer, PhD, Maxine, Professor of Behavioral Biology, Johns Hopkins University, School of Medicine 



-251- 



Swift, MD, PhD, Robert M., Professor of Psychiatry and Human Behavior, Brown University, 

Department of Bio Med Psychiatry and Human Behavior 
Szapocznik, PhD, Jose, Professor, Psychiatry and Behavioral Sciences and Director, Center for Family 

Studies, University of Miami, School of Medicine 
Taylor, Patricia A., Project Director, Faces and Voices of Recovery 
Tieman, Doug, President and Chief Executive Officer, Caron Foundation 
Trojan, Jodi, Program Evaluator, Cook Inlet Tribal Council 

Valentine, Phillip, Executive Director, Connecticut Community for Addiction Recovery 
Vocci, PhD, Francis, Director, Division of Pharmacotherapy and Medical Consequences, National 
Institute on Drug Abuse 

Walker, MSW, LCSW, MDiv, Robert J., Assistant Professor, University of Kentucky, Center on Drug 

and Alcohol Research 
Walsh, PhD, J. Michael, President, Walsh Group, PA 

Wenger, Sis, President and Chief Executive Officer, National Association for Children of Alcoholics 
Wetsman, MD, FAS AM, Howard C, Chief Medical Officer, Townsend; Author, QAA: Questions and 

Answers on Addiction 
White, MA, William, Senior Research Coordinator, Chestnut Health Systems 

Wilkins, MD, DFAPA, FASAM, Jeffery N., Lincy/Heyward-Moynihan Chair of Addiction Medicine, 
Vice Chair, Dept. of Psychiatry, Cedars-Sinai Medical Center, President, California Society of 
Addiction Medicine, Director, American Board of Addiction Medicine, Clinical Professor, 
Department of Psychiatry & Biobehavioral Sciences, David Geffen School of Medicine at UCLA 

Willenbring, MD, Mark, Director, Addictive Disorders Section, Minneapolis VA Medical Center 

Wilson, PhD, Julie Boatright, Director, Malcolm Wiener Center for Social Policy, John F. Kennedy 
School of Government, Harvard University 

Woods, Mary R., Chief Executive Officer, WestBridge Community Services 

Woody, MD, George E., Professor, Department of Psychiatry, University of Pennsylvania, Treatment 
Research Institute 

Yoast, PhD, MA, Richard A., Director, Office of Alcohol and Other Drug Abuse Prevention, Division of 

Healthy Lifestyles, American Medical Association 
Ziegler, MD, Penelope P., Medical Director Emeritus and Senior Consulting Psychiatrist, Williamsburg 

Place and The William J. Farley Center, and Associate Clinical Professor of Psychiatry, Virginia 

Commonwealth University 



-252- 



Appendix C 

National Addiction Belief and Attitude Survey (NABAS) 



Responses from 1,303 survey participants. The number corresponding to each response option represents 
the percent, among those responding to the question, that provided the particular response. 

1 . I am going to read you a list of health conditions and then please tell me which TWO or THREE 
do you think is most common in the United States. Would you like me to read this list again? 

64.4 Obesity and diabetes 

46.1 Cancer 

45.5 Heart disease 

29.7 Addiction to tobacco 

22.2 Addiction to alcohol 

16.8 Addiction to illegal drugs 
14.5 Depression 

1 1 .0 Addiction to prescription drugs 
9.0 Asthma 
0.4 Not sure 

2. Now I am going to read the same list again and this time please tell me which TWO or THREE do 
you believe cause the greatest harm in the United States. 



56.4 


Obesity and diabetes 


52.2 


Cancer 


43.7 


Heart disease 


28.0 


Addiction to tobacco 


26.4 


Addiction to illegal drugs 


23.6 


Addiction to alcohol 


11.0 


Addiction to prescription drugs 


10.6 


Depression 


3.2 


Asthma 


0.2 


Not sure 



3. I am going to mention some issues that could be a problem in your community. For each one I 

mention, please tell me how much of a problem you think it is in your community— a very serious 
problem, somewhat serious problem, not too much of a problem, or not a problem at all. 

Insufficient treatment programs and services for people addicted to illegal drugs 
28.9 Very serious problem 
27.2 Somewhat serious problem 
16.8 Not too much of a problem 
17.5 Not a problem at all 
9.7 Not sure 

Insufficient treatment programs and services for people with obesity and diabetes 
26.5 Very serious problem 
32.4 Somewhat serious problem 
16.0 Not too much of a problem 
17.8 Not a problem at all 
7.3 Not sure 



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Insufficient treatment programs and services for people addicted to tobacco 
19.9 Very serious problem 

28.0 Somewhat serious problem 
21.4 Not too much of a problem 
2 1 .4 Not a problem at all 

9.2 Not sure 

Insufficient treatment programs and services for people with depression 

18.7 Very serious problem 

33.4 Somewhat serious problem 

20. 1 Not too much of a problem 
16.9 Not a problem at all 

10.9 Not sure 

Insufficient treatment programs and services for people addicted to prescription drugs 

18.2 Very serious problem 

28.8 Somewhat serious problem 
18.7 Not too much of a problem 

19.3 Not a problem at all 

15.0 Not sure 

Insufficient treatment programs and services for people addicted to alcohol 

17.1 Very serious problem 

29. 1 Somewhat serious problem 

23.9 Not too much of a problem 

22.0 Not a problem at all 
7.9 Not sure 

Insufficient treatment programs and services for people with cancer 

17.6 Very serious problem 

20.5 Somewhat serious problem 

23.7 Not too much of a problem 

31.1 Not a problem at all 
7.0 Not sure 

Discrimination against people in recovery from addiction to alcohol, tobacco, prescription or other 
drugs 

15.8 Very serious problem 

25.6 Somewhat serious problem 

30.0 Not too much of a problem 

20.5 Not a problem at all 
8.2 Not sure 

Insufficient treatment programs and services for people with heart disease 

16.3 Very serious problem 

23.1 Somewhat serious problem 

23.9 Not too much of a problem 
3 1 .0 Not a problem at all 

5.6 Not sure 

Insufficient treatment programs and services for people with diabetes 

13.4 Very serious problem 

27.6 Somewhat serious problem 
19.0 Not too much of a problem 

27.7 Not a problem at all 
12.3 Not sure 



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Discrimination against people with mental illness 
12.9 Very serious problem 
22.7 Somewhat serious problem 

28.1 Not too much of a problem 

30.2 Not a problem at all 

6.0 Not sure 

Insufficient treatment programs and services for people with asthma 
6.9 Very serious problem 

18.1 Somewhat serious problem 
26.7 Not too much of a problem 
35.0 Not a problem at all 

13.2 Not sure 

4. If you were responsible for deciding who to hire at your place of work, and you learned that a 
qualified applicant (READ ITEM), would that make you more likely to hire that person, less 
likely, or would it not make a difference either way? (IF ANSWERED "MORE LIKELY," ASK:) 
Would you be much more likely or only somewhat more likely to hire someone who (READ 
ITEM)? (IF ANSWERED "LESS LIKELY," ASK:) Would you be much less likely or only 
somewhat less likely to hire someone (READ ITEM)? 

Is in recovery from an addiction to illegal drugs 

3.7 Much more likely 

3.7 Somewhat more likely 
37.9 Would not make a difference 

33.6 Somewhat less likely 
20.0 Much less likely 

1 .2 Not sure 

Is in recovery from an addiction to prescription medications 

1 .4 Much more likely 

5.9 Somewhat more likely 

48.7 Would not make a difference 

28.8 Somewhat less likely 

12.3 Much less likely 
2.9 Not sure 

Is in recovery from an addiction to alcohol 

2.3 Much more likely 

6.7 Somewhat more likely 

60.5 Would not make a difference 

18.7 Somewhat less likely 
9.2 Much less likely 

2.6 Not sure 
Has been treated for addiction to alcohol 

1.8 Much more likely 

2.9 Somewhat more likely 

65.8 Would not make a difference 
19.0 Somewhat less likely 

8.1 Much less likely 

2.5 Not sure 



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Has been treated for depression 

2.3 Much more likely 

4.7 Somewhat more likely 

71.9 Would not make a difference 

14.1 Somewhat less likely 

3.9 Much less likely 

3.0 Not sure 

Has been treated for obesity 

2.8 Much more likely 

2.3 Somewhat more likely 

84.6 Would not make a difference 
7.2 Somewhat less likely 

2.2 Much less likely 

0.9 Not sure 
Has been treated for heart disease 

1 .4 Much more likely 

4.2 Somewhat more likely 

83.5 Would not make a difference 

6.5 Somewhat less likely 
2.7 Much less likely 

1.7 Not sure 
Is a former smoker 

1 .4 Much more likely 

2.1 Somewhat more likely 

89.0 Would not make a difference 

4.9 Somewhat less likely 

1.7 Much less likely 
1.0 Not sure 

Is in treatment for diabetes 

2.0 Much more likely 

2.2 Somewhat more likely 

88.8 Would not make a difference 

4.2 Somewhat less likely 

1 .2 Much less likely 

1.6 Not sure 

Is in treatment for asthma 

2.1 Much more likely 

1 .2 Somewhat more likely 

90.7 Would not make a difference 

3.8 Somewhat less likely 
1.0 Much less likely 

1.0 Not sure 
Has been treated for cancer 

4.0 Much more likely 

4.3 Somewhat more likely 

85.6 Would not make a difference 

3.1 Somewhat less likely 
1.6 Much less likely 

1 .4 Not sure 



5. Now I am going to mention various substances some people may consume and I would like you to 
tell me what level of use would, in your personal opinion, indicate that a person has a serious 
problem. To give you an example, some people might say that a person who eats fried foods once 
a week does not have a problem but if someone eats fried foods several times a day then they do 
have a serious problem and should seek help to change their diet. 

When it comes to (READ ITEM), do you think any use at all indicates a person has a serious 
problem and should seek treatment, or is monthly use, weekly use, daily use, or use several times a 
day that would indicate a serious problem-or do you not think that any level of use of (READ 
ITEM) indicates a serious problem for which treatment is needed? 

Heroin 

84.0 Any use at all 

3.0 Monthly use 

2.5 Weekly use 

5.5 Daily use 

2.6 More than daily use 

1 .0 Does not indicate a problem at any level of use 
1.6 Not sure 

Cocaine 

76.0 Any use at all 

4.6 Monthly use 

5.1 Weekly use 

8.2 Daily use 

3.6 More than daily use 

1 . 1 Does not indicate a problem at any level of use 
1.5 Not sure 

Methamphetamine 

73.9 Any use at all 

4.0 Monthly use 

3.9 Weekly use 

9.4 Daily use 

4.0 More than daily use 

0.9 Does not indicate a problem at any level of use 

3.9 Not sure 
Non-medical use of prescription medications 

42.5 Any use at all 

8.2 Monthly use 
9.9 Weekly use 

19.7 Daily use 

9.9 More than daily use 

5.5 Does not indicate a problem at any level of use 

4.3 Not sure 
Marijuana 

35.8 Any use at all 

7.6 Monthly use 
9.2 Weekly use 

21.4 Daily use 

14.5 More than daily use 

7.0 Does not indicate a problem at any level of use 

4.5 Not sure 



-257- 



Cigarettes/Tobacco 

24.3 Any use at all 

1.9 Monthly use 

6.6 Weekly use 

22.0 Daily use 

27.5 More than daily use 

12.9 Does not indicate a problem at any level of use 

4.8 Not sure 
Alcohol 

6.8 Any use at all 

2.0 Monthly use 

7.4 Weekly use 

39.5 Daily use 

38.5 More than daily use 

2.8 Does not indicate a problem at any level of use 

3.0 Not sure 



6. Now let me read you a list of factors different people say may cause people to become addicted to 
(READ ITEM) and have you tell me which TWO or THREE you think are the primary factors 
causing addiction to (READ ITEM)? 

Tobacco 

43.5 Inability to resist peer pressure 

38.7 Easy availability of tobacco among youth 

37.7 Stress or anxiety about work, family or other problems 

33.0 Lack of willpower or self control 

25.4 A predisposition to addiction due to genetics or family history 

20.0 Lack of knowledge about addiction 

17.3 Emotional disorders or mental illness such as depression or anxiety 

3.8 Absence of religious faith or spiritual grounding 

3.0 Distorted moral values 

2.0 Other 
1.6 None 

1 .4 Not sure 
Alcohol 

47.6 A predisposition to addiction due to genetics or family history 
44.9 Stress or anxiety about work, family or other problems 

35.3 Emotional disorders or mental illness such as depression or anxiety 

29.7 Lack of willpower or self control 

29.2 Easy availability of alcohol among youth 

28.2 Inability to resist peer pressure 

11.1 Lack of knowledge about addiction 

6.8 Absence of religious faith or spiritual grounding 

5.9 Distorted moral values 

1.1 Other 
0.1 None 
0.6 Not sure 



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Prescription medications 

40.8 Emotional disorders or mental illness such as depression or anxiety 

36.7 Easy availability of prescription medications among youth 

36.9 Stress or anxiety about work, family or other problems 

27.5 A predisposition to addiction due to genetics or family history 
26.9 Lack of willpower or self control 

25.8 Lack of knowledge about addiction 

17.8 Inability to resist peer pressure 

5.6 Absence of religious faith or spiritual grounding 

6.8 Distorted moral values 

3.6 Other 

0.8 None 

1.8 Not sure 
Illegal drugs 

41.9 Inability to resist peer pressure 

35.1 Easy availability of illegal drugs among youth 

34.8 Emotional disorders or mental illness such as depression or anxiety 

29.9 A predisposition to addiction due to genetics or family history 
29.9 Stress or anxiety about work, family or other problems 

28.7 Lack of willpower or self control 

19.6 Lack of knowledge about addiction 

10.2 Distorted moral values 

9.4 Absence of religious faith or spiritual grounding 

1.8 Other 

1.0 None 

1 .2 Not sure 



7. What should the main treatment goal for someone addicted to (READ ITEM)? Should it be 

complete abstinence, reduced use, fewer negative consequences from use or the goal should be set 
by the patient? 



Illegal drugs 

65.7 Complete abstinence 
8.8 Reduced use 

4..0 Fewer negative consequences from use 
17.3 Goal should be set by the patient 

4.2 Not sure 
Alcohol 

60.0 Complete abstinence 
14.6 Reduced use 

1 .5 Fewer negative consequences from use 

21.1 Goal should be set by the patient 

2.8 Not sure 
Tobacco 

50.1 Complete abstinence 

17.6 Reduced use 

0.8 Fewer negative consequences from use 

29.7 Goal should be set by the patient 

1.9 Not sure 



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Prescription medications 

47.1 Complete abstinence 

22.7 Reduced use 

3.5 Fewer negative consequences from use 

20.8 Goal should be set by the patient 
6.0 Not sure 

8a. Suppose someone close to you realized they had a major problem with addiction to alcohol, 

tobacco, prescription or other drugs, how confident would you be that you knew or could find out 
where to go or call or send them to get the help they would need: very confident, somewhat 
confident, not too confident or not at all confident? 

50.9 Very confident 

30.7 Somewhat confident 

8.6 Not too confident 

8.5 Not confident at all 
1.3 Not sure 

8b. If someone close to you needed help for an addiction, where would you turn for information or 
help? (PROBE) Is there anywhere else you think of where you could turn for help or 
information? 

27.8 My doctor or primary care physician 

18.8 Internet or Yellow Pages or "look it up" or do "research" 

19.7 Other doctor, nurse, hospital, health clinic or health professional 

12.0 Alcoholics Anonymous (AA) 

10.7 Friend or family member 

9.8 Church, clergy or religious or spiritual leader 
11.0 Addiction treatment center 

9.2 Psychologist, psychiatrist or other mental health counselor 
7.2 Addiction "hotline" or "helpline" 

6.0 Narcotics Anonymous (NA) or other similar 12-step programs 

3.6 Place of work, office, Employee Assistance Program (EAP) 

3.0 Other mutual support or self-help programs such as Smart Recovery 

2.0 Student guidance counselor for a minor 

0.6 My insurance company 

1 .2 Would not know where to turn for help 

1.8 Not sure 

24.2 Other* 

* The number of responses in the "Other" option are quite varied and therefore, not 
specified here. 

8c. (ASKED ONLY OF THOSE WHO SAY "FRIEND/FAMILY MEMBER" OR "SOMEONE 

ELSE" in Q 8b) And is that someone with special knowledge or training when it comes to dealing 
with addictions or just someone you count on for good advice in general? 

56.8 Special knowledge or training 
30.7 Good advice in general 

12.4 Both 



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9. In general, how effective do you think treatment is for addiction to (READ ITEM) if the person 
admits they have a problem and wants to get better? Would you say treatment for (READ ITEM) 
addiction is usually very effective, somewhat effective, not too effective, or not effective at all? 
(IF RESPONDENT SAYS "IT DEPENDS OR IS "NOT SURE, ASK:) Well, if you had to give 
an answer about addiction treatment for people in general would you say it is usually very 
effective, somewhat effective, not too effective, or not effective at all? 

Prescription medications 

31.7 Very effective 

48.2 Somewhat effective 

8.0 Not too effective 

2.7 Not effective at all 

3.6 It depends 

5.8 Not sure 
Alcohol 

30.6 Very effective 
51.9 S omewhat effective 

7. 1 Not too effective 

3.1 Not effective at all 

4.3 It depends 
3.0 Not sure 

Tobacco 

25.3 Very effective 

47.8 Somewhat effective 

13.4 Not too effective 

5.4 Not effective at all 

4.3 It depends 
3.8 Not sure 

Illegal drugs 

24.4 Very effective 
49.2 Somewhat effective 
13.8 Not too effective 

3.7 Not effective at all 
3.6 It depends 

5.2 Not sure 

10a. How much would you say you know about treatment for addiction? Would you say you are very 
confident that you know what treatment for addiction involves, somewhat confident, not too 
confident, or not at all confident that you know what is really involved when someone gets 
treatment for addiction? 

18.8 Very confident 

42.8 Somewhat confident 

20.6 Not too confident 

16.5 Not confident at all 

1.4 Not sure 



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10b. When you think about treatment for addiction, what kinds of treatments come to mind? What are 
different types of addiction treatment you know about? (PROBE) Anything else? Are there any 
other types of treatment available for addiction that you know of? 

40. 1 Narcotic Anonymous (NA) or other similar 12-step programs 

39.7 Hospitals 

20. 1 Alcoholics Anonymous (AA) 

12. 1 Prescription medications for addiction-patches and pills, suboxone, naltrexone or 
methadone 

1 1.4 Residential rehabilitation clinics such as Betty Ford or Hazelden 

10.1 Outpatient clinic or day treatment programs 

8.2 Psychological therapies in either an individual or group setting 

6.0 Comprehensive addictions treatment combining prescribed medication, individual and 

group therapy, and mutual support groups 

5.6 Office-based treatment by a therapist or counselor 

5.3 Religious or spiritual recovery programs 
4.5 Hospital inpatient detoxification 

3.5 Other mutual support or self-help programs such as Smart Recovery 

2.3 Detoxification in a jail cell or prison 

1.8 Talking to priest or pastor 

0.7 Hotlines/Help lines, Quit lines 

0.5 Office-based treatment by a physician 

4.8 Other* (specify) 

* The number of responses in the "Other" option are quite varied and therefore, not 
specified here. 

4.0 None 
7.5 Not sure 

1 1 a. Now I would like to read two views about medicines to treat addictions and have you tell me 
which one comes closer to your personal point of view. 

Statement A: It is good news that there are medicines to treat addictions. 
81.0 Good news 

Statement B: It is not good news that there are medicines to treat addictions.* 

14.2 Not good news 
4.8 Not sure 

1 lb. Now I would like to read two views about medicines to treat addictions and have you tell me 
which one comes closest to your personal point of view. 

Statement A: It is good news that there are medicines to treat addictions, because addictions are 
medical conditions that medicine can help. 
54.6 Good news 

Statement B: It is not good news that there are medicines to treat addictions, because this only 
replaces one addiction with another.* 

38.3 Not good news 

7. 1 Not sure 



Asked of one -half of the respondents. 



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12. People have suggested various reasons why some people with addiction do not get the help they 
need. Which TWO or THREE of the following do you personally think are the main reasons why 
people with an addiction to alcohol, prescription or other drugs do not get help? Please let me 
know if you would like me to read the list again. (IF "ALL," ASK:) If you had to choose just two 
or three, which would you choose? 

72.0 Denial-refusal to admit the problem or not wanting to quit 

38.0 Fear of consequences like losing job, getting expelled from school or losing child custody 

29. 1 Fear of social embarrassment or shame 

28.3 Insufficient available or affordable treatment programs 

20.3 Don't believe treatment would help 

19.1 Fear of physical or emotional pain of withdrawal 

15.9 Insufficient information about how and where to get help 

1.0 Other 

3.4 All 

0.0 None 

0.5 Not sure 

13. Which TWO or THREE of the following are your main source of information about treatments for 
addiction to alcohol, tobacco, prescription or other drugs? 

37.7 A friend or family member's personal experience 

32.5 Health care professionals 

25.7 Internet 

24.4 News media such as newspapers or television news 

20. 1 Your own personal experience 

15.4 Advertisements for treatment programs 

13.2 Employee Assistance Programs (EAP) 

12.6 Entertainment media like movies and TV shows 
1 1 .4 Academic research and scholarly journals 

10.1 School guidance or health offices 
8.2 Magazines about celebrities and entertainment news 
2.6 Not sure 

14. Do you think public health insurance plans like Medicare or Medicaid that are paid for by the tax 
dollars of people like you should cover treatment for addiction to (READ ITEM) or do you not 
think so? (IF "YES," ASK:) Do you think public health insurance plans should provide patients 
with as much treatment as they need for the addictions to (READ ITEM) without limits or do you 
think there should be limits on addictions treatment such as "X" number of physician visits or "Y" 
number of days per year of hospital or other residential care? 

Prescription medications 

25.6 Yes, should cover treatment without limits 

42.3 Yes, should cover treatment with limits on days 
3.4 Not sure about limits 

22.8 No, should not cover treatment 
6.0 Not sure 



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Alcohol 

22.6 Yes, should cover treatment without limits 
41.6 Yes, should cover treatment with limits on days 
4.0 Not sure about limits 

28.3 No, should not cover treatment 
3.4 Not sure 

Illegal drugs 

25. 1 Yes, should cover treatment without limits 
38.1 Yes, should cover treatment with limits on days 

4.4 Not sure about limits 
27.8 No, should not cover treatment 

4.6 Not sure 
Tobacco 

21.0 Yes, should cover treatment without limits 

30. 1 Yes, should cover treatment with limits on days 
2.8 Not sure about limits 

42.4 No, should not cover treatment 

3.8 Not sure 

Now I am going to mention some approaches society could take to address the problem of 
addiction to alcohol, tobacco, prescription and other drugs. For each approach, please tell me how 
important you think it is— very important, somewhat important, not too important, or not important 
at all? 

Educate the public about the disease of addiction and the possibility of recovery 
73.1 Very important 

22. 1 Somewhat important 
2.0 Not too important 

1.9 Not important at all 
0.9 Not sure 

Fund research to improve treatment and recovery options for addiction to alcohol, tobacco, 
prescription or other drugs 
57.6 Very important 

36.5 Somewhat important 

2.6 Not too important 
1.9 Not important at all 
1.4 Not sure 

Increase the number and availability of effective treatment and recovery programs 
57.4 Very important 

34.2 Somewhat important 

3.7 Not too important 
2.7 Not important at all 
2.0 Not sure 

End discrimination in the areas of employment, insurance and housing against people who have 
used drugs in the past but are now in recovery 

48.6 Very important 
35.2 Somewhat important 

8.2 Not too important 
5.4 Not important at all 
2.6 Not sure 



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Increase criminal penalties for people who use drugs illegally 

38.6 Very important 

27.4 Somewhat important 
14.9 Not too important 

16.7 Not important at all 
2.3 Not sure 

The following questions are personal in nature, but we can assure you that this is a confidential survey 
and your responses will be kept completely private. 

16. To your knowledge, has anybody close to you, like a parent, child, sibling, close friend, etc., ever 
had a problem with addiction to alcohol, prescription drugs or other drugs? 

68.3 Yes 
30.3 No 

0.6 Not sure 

0.8 Refused 

17. To your knowledge, has anybody close to you, like a parent, child, sibling, close friend, etc., ever 
had a problem with addiction to tobacco? 

78.2 Yes 
19.7 No 

1 .2 A smoker but not addicted 

0.5 Not sure 

0.4 Refused 

18a. Are you, yourself, addicted to alcohol, or prescription or other drugs right now, or have you been 
addicted to them in the past? I know this is a sensitive topic, but let me reassure you that this is for 
research purposes only and that all your responses will be completely anonymous and confidential. 

16.9 Yes 
82.0 No 

0.7 Not sure 

0.3 Refused 

18b. What are you now or have you been addicted to in the past? 

40.0 Alcohol 

12.5 Prescription drugs 
50.9 Other drugs 

5.1 Not sure 
7.6 Refused 



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18c. Are you, yourself, addicted to tobacco right now, or have you been addicted to it in the past? I 
know this is a sensitive topic, but let me reassure you that this is for research purposes only and 
that all your responses will be completely anonymous and confidential. 

34.3 Yes 

61.6 No 

3.1 A smoker but not addicted 
0.7 Not sure 

0.2 Refused 

19a. Do you currently have health insurance? 

85.8 Yes 

13.0 No 

1.0 Not sure 
0.3 Refused 

19b. (ASKED ONLY OF THOSE WHO SAY "YES," THEY CURRENTLY HAVE HEALTH 

INSURANCE IN Q. 19a) Which of the following most closely describes the type of health care 
plan you have— a traditional fee-for-service plan, in which the patient or the insurance company 
pays for each doctor visit or hospitalization, and HMO or PPO, in which most doctor visits or 
hospitalizations are covered without charging separately, Medicare or Medicaid, or some other type 
of plan? 

21.6 Yes, traditional fee-for-service plan 

46.1 Yes, an HMO or PPO 
24.3 Yes, Medicare or Medicaid 
10.3 Yes, some other type of plan 

2.2 Yes, not sure which type of plan 
1.0 Not sure 

0.4 Refused 

FACTUALS : Now I am going to ask you a few questions for statistical purposes only. 

Fl. How old are you? (IF "REFUSED," ASK:) Well, would you tell me which age group you belong 



to? 




9.6 


18-24 


9.5 


25-29 


11.9 


30-34 


5.4 


35-39 


10.3 


40-44 


12.2 


45-49 


8.3 


50-54 


7.8 


55-59 


7.9 


60-64 


5.3 


65-69 


4.4 


70-74 


7.3 


75 and over 


0.2 


Refused 



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F2a. Are you currently employed? (IF "CURRENTLY EMPLOYED," ASK:) What type of work do 
you do? (IF "NOT CURRENTLY EMPLOYED," ASK:) Are you a student, homemaker, retired, 
or unemployed and looking for work? 

Not currently employed 

3.3 Student 

5.5 Homemaker 

20.6 Retired 

5.4 Unemployed, looking for work 
63.1 Other - Currently employed 

2.0 Not sure 

F2b. Do you work full-time or part-time? 

47.9 Yes, employed full-time 
14.4 Yes, employed part-time 

35.4 No, not currently employed 
2.3 Not sure 

F3. What is the last grade that you completed in school? 

1.2 Grade school 

6.8 Some high school 

30.5 High school graduate 
19.4 Some college, no degree 

12. 1 Vocational training/2 year college 

14.6 4 year college^achelor's degree 

2.3 Some postgraduate work, no degree 

8.7 2-3 years postgraduate work/master's degree 

2.4 Doctoral/law degree 

2.0 Not sure/refused 

F4. Regardless of how you may be registered, how would you describe your overall point of view in 
terms of the political parties? Would you say that you are? 

30.4 Mostly Democratic 

11.1 Leaning Democratic 

21.2 Completely Independent 

9.5 Leaning Republican 
18.8 Mostly Republican 

9. 1 Not sure 

F5. Thinking about your general approach to issues, do you consider yourself to be liberal, moderate 
or conservative? 

21.7 Liberal 

35.5 Moderate 
32.5 Conservative 

10.3 Not sure 



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F6. For statistical purposes only, would you please tell me which one of the following categories 
represents your total household income? Just stop me when I get to the correct category. 

18.2 Less than $25,000 

24.5 $25,000 to $50,000 

19.4 $50,000 to $75,000 

11.7 $75,000 to $100,000 
8.9 $100,000 to $150,000 
5.5 More than $150,000 

11.8 Not sure/refused 

F7. Finally, are you from a Hispanic or Spanish-speaking background? 

13.0 Yes, Hispanic 
86.7 No, not Hispanic 
0.3 Not sure/refused 

F8. What is your race-white, black, Asian or something else? 

76.0 White 

11.7 Black 

1.3 Asian 

3.0 Other 

7.0 Hispanic 

1.0 Not sure/refused 



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Appendix D 

Survey of New York State Addiction Treatment Directors 



Responses from 83 survey participants. The number corresponding to each response option represents the 
percent, among those responding to the question, that provided the particular response. 



I. ORGANIZATION AND PRACTICE 



Which of the following provides the funding to operate your facility? (CHECK ALL THAT APPLY) 
10.8 A private for-profit organization 

54.2 A private nonprofit organization 
53.0 State/federal government 

19.3 Other 



2. What types of payment for addiction/substance abuse treatment services are accepted by your 
facility? (CHECK ALL THAT APPLY) 
10.8 Payment is not necessary (free treatment) GO TO #3 

88.0 Cash or self-payment 

30.1 Medicare 

86.7 Medicaid 

39.8 State financed health insurance plan other than Medicaid (e.g., Children's Health Insurance 
Plan) 

28.9 Municipal, county, or state- administered grant funding (either derivative of the federal 
Substance Abuse Treatment Block Grants, or not) 

16.9 Federal military insurance (TriCare, CHAMPUS, or CHAMPVA) 
65.1 Private health insurance 
20.5 Other 



What are the primary types of service offered in your program? (CHECK ALL THAT APPLY) 

8.4 Inpatient general hospital 

12.0 Inpatient specialty (addiction or psychiatric) hospital 

28.9 Residential non-hospital 

68.7 Outpatient non-methadone 

13.3 Outpatient methadone 

22.9 Other* (PLEASE SPECIFY) 

*The high number of responses in the "Other" option are quite varied and therefore, not 
specified here. Other responses include chemical dependency centers, case management, 
and counseling. 

Which of the following describes the kind of services provided in your program? (CHECK ALL 
THAT APPLY) 

28.9 Medical care 

47.0 Pharmacological treatments 

48.2 Treatment for co-occurring mental and physical health issues 
100.0 Counseling/therapy 
59.0 Self-help/mutual aid/social support 
26.5 Other 



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5. Is your facility affiliated with a religious organization, or is it not? 

3.6 Affiliated 
96.4 Not affiliated 

6. Is your facility currently smoke free, or is it not? 

98.8 Smoke free 
1.2 Not smoke free 

7. Does your facility offer treatment for nicotine addiction, or does it not? 
89.2 Offers 

10.8 Does not offer 

8. What is the name of the county in which the treatment facility of which you are the director is located? 



3.0 


Albany 




Bronx 


1 o 

1.2 


Broome 


1 o 

1.2 


Chemung 


1 O 

1.2 


Clinton 


1 O 

1.2 


Columbia 


i i 
1 .z 


Cortland 


1 o 

1.2 


Dutchess 


3.6 


Erie 


1.2 


Genesee 


1 O 

1.2 


Greene 


1 f\ o 

ID. 8 


Kings 


J.O 


Nassau 


3.6 


Monroe 


1.2 


Montgomery 


9.6 


New York 


1.2 


Oneida 


3.6 


Onondaga 


1.2 


Ontario 


2.4 


Orange 


1.2 


Putnam 


3.6 


Queens 


1.2 


Rensselaer 


1.2 


Richmond 


2.4 


Rockland 


2.4 


Schenectady 


1.2 


Seneca 


2.4 


St. Lawrence 


8.4 


Suffolk 


1.2 


Sullivan 


1.2 


Ulster 


1.2 


Wayne 


4.8 


Westchester 


1.2 


Yates 



-270- 



9. For each type of clinical staff listed below, how many full-time equivalent (FTE) staff who 
provide treatment for addiction/substance abuse are currently employed at your facility? (Average 
FTE staff reported below). 

1.2 Physicians (MD/DO) e.g., general practitioner, internist, family physician, psychiatrist, 

addiction medicine specialist 
1.2 Other doctoral-level (PhD, PsyD, SciD, DrSW) e.g., psychology, social work, counseling 
0.7 Physician Assistants/Nurse Practitioners 
4.4 Master's e.g., psychology, social work, counseling 

6.7 Certified/licensed addiction and substance abuse counselors e.g., CDCs, CASACs, LACs 

(even if counted in categories above) 
5.4 Other* (PLEASE SPECIFY) 

* The high number of responses in the "Other" option are quite varied and therefore, not 
specified here. Other responses include CASACs, registered nurses and BA-level 
counselors. 

10. What is the total number of full-time and part-time clinical staff currently employed at your 
facility? Please include all staff members in your count. (Average number of clinical staff 
reported below). 

25.0 Clinical staff employed. 

1 1 . Last month, about how many staff members in total resigned, were let go, retired or left your 
facility? Please include all staff members in your count. 

64.2 None 



12. On average, about how long do staff who are directly involved in providing client treatment stay 
employed with your facility? 
0.0 1 month or less 

0.0 More than 1 month to less than 3 months 

0.0 3 months to less than 6 months 

0.0 6 months to less than 9 months 

1.3 9 months to less than 1 year 

6.3 1 year to less than 1.5 years 

3.8 1.5 years to less than 2 years 
20.3 2 years to less than 3 years 
24.1 3 years to less than 5 years 
44.3 More than 5 years 



21.0 
12.3 
2.5 



1 

2 
3 



-271- 



13. Under which of the following conditions would a client/patient be dismissed by your center or 
asked to leave the program before completing the treatment course? (CHECK ALL THAT 
APPLY) 

3 1 .3 Client/patient using drugs or alcohol 

75.9 Client/patient bringing drugs or alcohol onto the facility premises 

12.0 Client/patient being unable to pay for treatment (e.g., private sources of payment run out; 
insurance stops covering costs) 

69.9 Other* (PLEASE SPECIFY) 

* The high number of responses in the "Other" option are quite varied and therefore, not 
specified here. Other responses include aggressive and violent behaviors, non-compliance, 
smoking, and legal issues. 

14. What are the top two sources from which clients/patients are referred to your facility for 
treatment? (CHECK UP TO TWO) 

27.7 Individual/self-referrals 
6.0 Family 

1 .2 Private physician 
22.9 Alcohol or other drug counselors (e.g., CASACs) 
2.4 Other health care professionals (e.g., physicians, nurses) 
3.6 Schools/educational organizations 
3.6 Employers/employee assistance programs 

18.1 Other community organizations 

42.2 Criminal justice/court/drug court (exclusive of DUI/OWI) 

45.8 Criminal j ustice/ court/ drug court referrals(DUI/ O WI) 

22.9 Other sources 

15. How would you describe the attitude of the surrounding community toward having a treatment 
facility in the neighborhood? (CHECK THE ONE THAT BEST APPLIES) 

2.4 Generally hostile 

43.4 Neither hostile nor supportive 
48.2 Generally supportive 

6.0 Not applicable 

16. If your facility does any advertising or outreach to attract patients/clients, which two of the 
following methods does it use most often? (CHECK UP TO TWO) 

12.0 This facility does not do any advertising or outreach 

23.5 Local print/fliers 
4.8 Television 

27.7 Internet 

10.8 Hospitals/doctors' offices 
21.7 Community centers 
48.2 Other 



-272- 



17. Which of the following steps does this facility take to continually improve treatment quality? 
(CHECK ALL THAT APPLY) 

0.0 There are no quality improvement efforts at this facility 

85.5 Require continuing education for staff 

91.6 Provide continuing education opportunities for staff 

75.9 Make available relevant publications discussing advances in treatment practices 
85.5 Provide mentorship/supervision for staff 

63.9 Forge collaborations with other facilities/organizations to offer additional off-site services 

to patient/clients 
28.9 Other* (PLEASE SPECIFY) 

* The high number of responses in the "Other" option are quite varied and therefore, not 
specified here. Other responses include performance improvement committees and in- 
service training. 

II. ATTITUDES TOWARD ADDICTION 

18. For each of the following health conditions please indicate whether you think. . . 

• It cannot be treated at all; once a person has it, he or she always will suffer from it and its 
symptoms; 

• It can be managed so that the symptoms are kept in check even though the individual 
continues to have the underlying problem; or 

• It can be treated successfully so that the individual no longer suffers from the problem. 





Cannot be 


Can be 


Can be treated 




treated at all 


managed 


successfully 


Depression 


1.2 


47.0 


51.8 


Addiction to alcohol 


1.2 


41.0 


57.8 


Diabetes 


1.2 


79.5 


19.3 


Asthma 


2.4 


79.5 


18.1 


Addiction to drugs other than nicotine or alcohol 


1.2 


42.2 


56.6 


Heart disease 


2.4 


73.5 


24.1 


Addiction to nicotine 


1.2 


33.7 


65.1 



19. Which of the following do you think are the main factors involved in developing. . . 

(i) Addiction to tobacco? (Please select a maximum of two primary factors) 

(ii) Addiction to alcohol? (Please select a maximum of two primary factors) 

(iii) Addiction to prescription/illegal drugs? (Please select a maximum of two primary factors) 









Addiction to 




Addiction to 


Addiction 


prescription 




tobacco 


to alcohol 


illegal/drugs 


A physical health problem 


26.5 


26.5 


51.8 


A mental health problem 


18.1 


38.6 


39.8 


A genetic problem 


22.9 


56.6 


38.6 


A behavioral problem 


48.2 


44.6 


43.4 


A moral problem 


6.0 


15.7 


13.3 


A spiritual problem 


7.2 


21.7 


14.5 


A reliance on the substance as an emotional crutch 








in response to negative life events 


49.4 


62.7 


60.2 


A problem of willpower or self control 


12.0 


12.0 


10.8 



-273- 



20. What should be a treatment provider's main treatment goal for. . . * 

(i) Someone addicted to tobacco? 

(ii) Someone addicted to alcohol? 

(iv) Someone addicted to prescription/illegal drugs? 

*The survey allowed respondent to choose more than one option for this question. 

Addicted to 



Addicted to Addicted prescription 

tobacco to alcohol illegal drugs 

Complete abstinence from the substance 49.4 61.4 66.3 

Reduced use of the substance 10.8 3.6 8.4 

Fewer negative consequences from use of the 

substance 4.8 10.8 13.3 

Goal should be set by the patient 41.0 25.3 30.1 

Other 3.6 2.4 3.6 



21. In your opinion, where should the money come from to pay for treating substance abuse and 
addiction? (CHECK UP TO THREE SOURCES) 

If a source that you think the money should come from is not on the list below, please check 
"Other" and write in your answer. 



30 


.1 


General tax revenues (e.g., income tax) 


60 


.2 


Increased taxes on alcohol 


54. 


.2 


Increased taxes on cigarettes 


43 


.4 


Fines for individuals driving under the influence of alcohol or other drugs (DUIs) 


25. 


.3 


Fines for commercial establishments that sell alcohol or cigarettes to minors 


20 


.5 


Funds saved from cutting government spending in other areas 


34. 


.9 


Private insurance 


13 


.3 


Self-pay 


9 


.6 


Other* (PLEASE SPECIFY) 






* The high number of responses in the "Other" option are quite varied and therefore, not 






specified here. Other responses include health insurance and Medicaid. 



III. ATTITUDES TOWARD TREATMENT 

22. How important is it for a treatment facility to have each of the following comprehensive 
assessment services available to clients/patients? 





Not at all 


Slightly 


Moderately 


Very 




important 


important 


important 


important 


Substance use behavior 


0.0 


0.0 


0.0 


100.0 


Other mental health conditions 


0.0 


0.0 


2.4 


97.6 


Other physical health conditions 


0.0 


1.2 


16.9 


81.9 


Family history of substance use 


0.0 


0.0 


12.0 


88.0 


Social/peer history of substance abuse 


0.0 


3.7 


19.5 


76.8 


Family/social network support systems 


0.0 


1.2 


12.2 


86.6 


Economic circumstances 


1.2 


8.5 


35.4 


54.9 


Religious/spiritual involvement 


1.2 


13.3 


41.0 


44.6 



-274- 



23. How important is it for a treatment facility to have each of the following interventions/therapies 
available to clients/patients? 





Not at all 


Slightly 


Moderately 


Very 




important 


important 


important 


important 


Detoxification 


8.8 


12.5 


21.3 


57.5 


Motivational interviewing 


0.0 


3.6 


24.1 


72.3 


Cognitive behavioral therapy 


0.0 


3.6 


24.1 


72.3 


Family therapy 


0.0 


4.9 


45.1 


50.0 


Religious/ spiritual interventions 


7.4 


29.6 


40.7 


22.2 


Mental health management (offered 


0.0 


3.6 


16.9 


79.5 


along with substance abuse treatment) 










Medical treatment for conditions such 


2.4 


11.0 


26.8 


59.8 


as Hepatitis C, HIV, TB, STDs, and 










other chronic medical illnesses (orrered 










along with substance abuse treatment) 










Pharmacology therapies 










Methadone maintenance for addictive 


13.4 


30.5 


28.0 


28.0 


disorders 










Other pharmacological interventions 


4.9 


17.1 


34.1 


43.9 


for addictive disorders (e.g., 










buprenorphine, disulfiram, naltrexone) 










Pharmacological interventions for co- 


1.2 


6.1 


18.3 


74.4 


occurring mental health conditions 










Pharmacological interventions for pain 


7.5 


18.8 


35.0 


38.8 


management 










Complementary/ alternative medicine 


4.8 


31.3 


33.7 


30.1 


approaches, such as acupuncture, 










meditation 










Recreation therapy/leisure skills 


0.0 


9.6 


38.6 


51.8 


training 










How important is it for a treatment facility to offer each of the following? 






Not at all 


Slightly 


Moderately 


Very 




important 


important 


important 


important 


Transportation services 


4.8 


21.7 


26.5 


47.0 


Child care services 


7.2 


21.7 


27.7 


43.4 


Employment/vocational services 


2.4 


7.3 


31.7 


58.5 


Housing services 


3.7 


14.6 


32.9 


48.8 


Referral to programs such as AA, 


1.2 


2.4 


21.7 


74.7 


Narcotics Anonymous, SMART 










Recovery 










Recovery support programs (e.g., AA, 


1.2 


9.6 


25.3 


63.9 


Narcotics Anonymous, SMART 










Recovery) 










Relapse prevention (e.g., long-term 


0.0 


2.4 


10.8 


86.7 



case management) 



-275- 



25. Which one of the following types of professionals do you think is best qualified to provide 
addiction treatment services? 

71.3 Substance abuse counselors 

16.3 Social workers 
1.3 Nurses 

7.5 Psychologists 
1.3 Physicians 

2.5 Persons who are recovered addicts or recovering from addiction 

26. Do you think that only graduate-level clinicians/staff should provide addiction treatment services 
while non-graduate-level substance abuse counselors provide recovery support services OR do 
you think that non-graduate-level clinicians/staff should provide both addiction treatment services 
and recovery support services? 

Note: 

Graduate-level clinicians/staff refers to those with degrees/qualifications such as the following: 
MD, PhD, MA, RN, NP. 

Addiction treatment services refers to services such as the following: cognitive/behavioral 
therapy, pharmacotherapy. 

Recovery support services refers to services such as the following: connection to mutual support 
programs; legal, housing, other social and health services; providing social support. 

25.6 Only graduate-level professionals should provide the actual treatment, while counselors 
provide recovery support services 

74.4 Non-graduate- level clinicians/staff should provide actual treatment and recovery support 
services 

27. How important do you think it is for addiction treatment clinicians/staff to have each of the 
following qualifications? 





Not at all 


Slightly 


Moderately 


Very 




important 


important 


important 


important 


Personal experience with addiction 


38.6 


28.9 


25.3 


7.2 


College degree (e.g., BA/BS) 


6.1 


13.4 


53.7 


26.8 


Master's degree (e.g., 


10.8 


19.3 


45.8 


24.1 


MA/MS/MPH/MSW) 










Doctoral degree (e.g., PhD/DSW) 


40.7 


33.3 


22.2 


3.7 


Medical degree (e.g., MD/DO) 


35.8 


27.2 


27.2 


9.9 


Specific training in addiction treatment 


0.0 


0.0 


0.0 


100.0 



-276- 



28. If training were offered, which one or two training topics would be most helpful to you 
personally? (CHECK UP TO TWO RESPONSES) 

12.0 Diagnosis/assessment via interview 

7.2 Using standardized screening instruments 

25.3 Etiology and prevalence of co-occurring disorders 

37.3 Preferred treatment practices 

14.5 Motivational interviewing 

22.9 Specialized group treatments 

16.9 Pharmacological treatments 

8.4 Assertive case management approaches 
9.6 Specialized 12-step facilitation approaches 

19.3 Individual/group psychotherapies 

12. 1 Other* (PLEASE SPECIFY) 

* The high number of responses in the "Other" option are quite varied and therefore, not 
specified here. Other responses include Evidence-Based practice and Cognitive-behavioral 
therapy. 

29. Which of the following describes your opinion on the best way to structure the delivery of 
substance-addiction treatment in the U.S.? (CHECK THE ONE THAT BEST APPLIES) 

11.3 The system should be integrated into the medical system such that addiction is treated as a 
health condition by heath care professionals (GO TO #3 1) 

7.5 The system should revolve around a recovery support model, with self-help/mutual support 
programs as the main intervention (GO TO #31) 

66.3 The system should be two-tiered with health care professionals providing 

psychotherapeutic and pharmacological interventions and individuals in recovery providing 
recovery support services (GO TO #31) 

15.0 Nothing should change 

30. Why did you say that nothing should change? (n=12, those who answered "Nothing should 
change" in Q29) 

33.3 Because the system is structured in the best possible way 

8.3 Because a change in the way that treatment for addiction is delivered would be too costly 
8.3 Because change in the way that treatment for addiction is delivered would be too disruptive 

to individuals involved in treatment delivery 
0.0 Because we do not know how to change the treatment system 
50.0 Other reason 



-277- 



31. To what extent does each of the following stand in the way of people looking for needed 
treatment for addiction/substance abuse? 





Not at all 


Somewhat 


Very much 


Denial of an addiction problem 


U.U 


1 A C 

14. j 


85.5 


Belie! that treatment does not work 


3.6 


63.9 


32.5 


Fear that one will be discriminated against if 


12. (J 


A O O 

48.2 


39.0 


looking for treatment 








Fear of losing child custody (to the state or to 


1.2 


25.3 


73.5 


another individual competing for custody) 








Fear of losing job 


3.6 


34.9 


61.4 


Fear of being sent to prison or jail 


16.9 


41.0 


42.2 


Inability to pay /lack of or insufficient medical 


9.6 


44.6 


45.8 


insurance 








Waiting lists that are too long 


37.8 


40.2 


22.0 



32. To what extent does each of the following stand in the way of people receiving needed treatment 
for addiction/substance abuse? 

Not at all Somewhat Very much 
Lack of a treatment facility that is conveniently 20.7 62.2 17. 1 

located 

Lack of a treatment facility providing services that 15.9 45. 1 39.0 

are suited to the individual client's needs 

Lack of ability to pay for treatment (including lack 14.6 42.7 42.7 

of private sources of funds and/or insurance 

coverage) 

33. To what extent does each of the following stand in the way of treatment providers in New York 
State's ability to provide effective services to people in need of addiction/substance abuse 
treatment? 





Not at all 


Somewhat 


Very much 


Insufficient program funding 


2.4 


35.4 


62.2 


Insufficient insurance coverage for clients/patients 


3.6 


36.1 


60.2 


Insufficient salaries to attract and retain high- 


3.6 


21.7 


74.7 


quality staff 








Insufficient number of trained counselors 


10.8 


47.0 


42.2 


(CASACs) 








Insufficient number of trained Master' s-level 


19.5 


52.4 


28.0 


professionals 








Insufficient number of trained PhD-level 


54.3 


37.0 


8.6 


professionals 








Insufficient number of trained MD/DO-level 


35.8 


51.9 


12.3 


professionals 








Insufficient number of appropriately trained staff 


3.7 


40.2 


56.1 


with the qualifications necessary to provide 








treatment for co-morbid physical or mental health 








conditions 








Insufficient number of appropriately trained staff 


15.7 


57.8 


26.5 



with the qualifications necessary to provide 
pharmacological therapies 



-278- 



Not at all Somewhat Very much 

Insufficient federal- or state-level education and 34.9 47.0 18.1 
training requirements for individuals providing 
addiction treatment 

Insufficient professional standards related to 41.0 38.6 20.5 
knowledge and clinical skills for individuals 
providing addiction treatment 

Limited motivation among staff members to be 33.7 42.2 24.1 
knowledgeable about evidence-based best practices 

Insufficient access to information about best 36.1 50.6 13.3 
practices 

High volume of paperwork (reporting requirements 1.2 22.0 76.8 
that take up too much time and resources) 



34. How important do you think it is that there be national standards for how addiction/substance 
abuse treatment services should be delivered to patients/clients? 

11.0 Not at all important (GO TO #36) 
18.3 Slightly important 

29.3 Moderately important 
41.5 Very important 

35. Which of the following would be in the best position to decide on such national standards for the 
delivery of addiction/substance abuse treatment services? (CHECK THE ONE THAT BEST 
APPLIES) (n=72, those who did not answer "Not at all Important" in Q34) 

11.1 The federal government 

40.3 National professional organizations 
36. 1 State professional organizations 
12.5 Other (PLEASE SPECIFY) 



IV. EVALUATION 



36. What are the three main ways your program evaluates how well it is doing? (CHECK UP TO 
THREE RESPONSES) 

0.0 Our program does not conduct evaluations (GO TO #37) 

8.4 Informal reports of staff perceptions 
54.2 Random client feedback/testimonials 
43.4 Drug test results 
68.7 Program completion rates 

2.4 Reduction in use based on self-report of clients only 

24. 1 Reduction in use based on self- report of clients AND information from other sources 
7.2 Abstinence from use based on self-report of clients only 

42.2 Abstinence from use based on self-report of clients AND information from other sources 
2.4 Remission of symptoms based on self-report of clients only 

22.9 Remission of symptoms based on self-report of clients AND information from other sources 
1 -2 Reduced recidivism rates for criminal offenders based on self-report of clients only 

13.3 Reduced recidivism rates for criminal offenders based on self-report of clients AND other 
information from justice departments 



-279- 



37. At what stage(s), if any, in the treatment of an individual patient, does your program assess how 
well treatment is working? (CHECK ALL THAT APPLY) 

2.4 Our program does not assess how well treatment is working (GO TO #38) 

60.2 At treatment program exit 
20.5 One month after treatment 

37.3 2 to 6 months after treatment 
24. 1 7 to 12 months after treatment 

8.4 More than one year but less than five years after treatment 
2.4 Five years or more post-treatment 

38. In your opinion, what are the three primary ways a program should assess its effectiveness, 
assuming that a program has sufficient resources for this? (CHECK UP TO THREE 
RESPONSES) 

0.0 Program effectiveness does not require evaluation 

7.2 Informal reports of staff perceptions 

45.8 Random client feedback/testimonials 

32.5 Drug test results 

57.8 Program completion rates 

2.4 Reduction in use based on self-report of clients only 

33.7 Reduction in use based on self-report of clients AND information from other sources 
1 .2 Abstinence from use based on self-report of clients only 

45.8 Abstinence from use based on self-report of clients AND information from other sources 
1.2 Remission of symptoms based on self-report of clients only 

34.9 Remission of symptoms based on self-report of clients AND information from other sources 
0.0 Reduced recidivism rates for criminal offenders based on self-report of clients only 

26.5 Reduced recidivism rates for criminal offenders based on self-report of clients AND other 
information from justice departments 

V. RECOMMENDATIONS 

39. Given sufficient resources, what are three ways you would change your program to improve 
treatment quality at your facility? 

26.8 Hire more staff with experience/higher education 
19.1 More access to education/resources/training 
10.0 Decrease caseload/paperwork 

9.6 More sessions/groups/treatment options 

6.8 Better case management (employment, housing, child care) 

6.4 Better pay for staff 

4.6 More space/change facility 

3.6 Add mental health component in treatment 

1.8 Use electronic records/administrative technology 

11.4 Other 



-280- 



40. Given sufficient resources, what are three ways you would suggest for improving the treatment 
system for addiction or substance abuse in New York? 

15.1 Better funding for training/staff resources 
13.7 Decrease paperwork/regulations 

9.0 Multi-care approach that includes mental health/referrals 

8.5 Better access to inpatient care/treatment 

8.0 Better pay for staff 

6.6 Enhance quality of services and programs 

6.6 Hire more staff with experience/higher education 

6. 1 Fix insurance issues/billing 

5.6 Better case management (employment, housing, child care) 
2.4 Use electronic records/administrative technology 
1.9 More sessions and groups available in treatment 
1.4 Decrease caseload 
16.5 Other 

VI. INDIVIDUAL DEMOGRAPHICS OF PROGRAM DIRECTOR PARTICIPATING IN 
THIS SURVEY 

41. In what year were you born? 

29.5 1938 - 1950 
60.3 1951 - 1970 

10.3 1971 - 1981 

42. Are you Hispanic/Latino/Latina or of Spanish origin? 

7.4 Yes 

92.6 No 

43. With which racial or ethnic group do you identify? 
75.6 White 

15.9 African American 

0.0 Asian American/Pacific Islander 

0.0 Native American 

8.5 Other 

44. What is your gender? 
47.6 Male 

52.4 Female 

45. What is the highest level of education you have completed? 

0.0 Less than high school graduation (GO TO #47) 

1 .2 High school graduate or GED (GO TO #47) 

14.5 Some college or associate degree (GO TO #47) 
16.9 Four-year college degree (GO TO #47) 

67.5 Graduate or post-graduate degree 



-281- 



46. What is your professional title? (CHECK THE ONE BEST APPLIES) (n=54, of those who 
answered "Graduate or post-graduate degree" in Q45). 

0.0 Physician 
11.1 Psychologist 

0.0 Physician Assistant 

0.0 Nurse Practitioner 

0.0 Registered Nurse 

0.0 Licensed Practicing Nurse 
40.7 Social worker 

5.6 Addictions counselor 

42.6 Other* (PLEASE SPECIFY) 

* The high number of responses in the "Other" option are quite varied and therefore, not 
specified here. Other responses include Director, MBA, and Administrator 

47. Do you have specific training in addiction treatment, or do you not? 
88.0 Have specific training* (PLEASE SPECIFY) 

* The high number of responses in the "Have Specific training" option are quite varied and 
therefore, not specified here. Other responses include CASAC training hours, addiction 
fellowships and classes. 

12.0 Do not have specific training 

48. How many years of experience do you have in the field of addiction treatment? 

1.2 Less than 1 year 
1 .2 1 year to less than 2 years 
0.0 2 years to less than 4 years 
2.4 4 years to less than 6 years 
7.2 6 years to less than 9 years 
6.0 9 years to less than 10 years 
81.9 1 years or more 

49. Do you think that being a recovered addict or recovering from addiction should be a prerequisite 
for being a treatment director, or should it not? 

30. 1 No, it would not help the position and should not be a prerequisite 

68.7 It might help but should not be a prerequisite for the position 
1 .2 Yes, it would help and it should be a prerequisite 



-282- 



VII. REFERRALS 



50. Do you ever refer patients to see private physicians who practice addiction medicine outside of 
your facility, or do you never do that? 

53.0 Refer 

47.0 Never refer (END. THANK YOU) 

51. If yes, about what proportion of patients do you refer per year? 
48.8 Less than 5% 

26.8 5% - 10% 

17.1 11% -25% 
4.9 26% -50% 
2.4 Over 50% 



-283- 



-284- 



Appendix E 

Survey of New York State Addiction Treatment Staff 



Responses from 141 survey participants. The number corresponding to each response option represents 
the percent, among those responding to the question, that provided the particular response. 

I. ATTITUDES TOWARD ADDICTION 

1 . For each of the following health conditions please indicate whether you think. . . 

• It cannot be treated at all; once a person has it, he or she always will suffer from it and its 
symptoms; 

• It can be managed so that the symptoms are kept in check even though the individual 
continues to have the underlying problem; or 



• It can be treated successfully so that the individual no longer suffers from the problem. 





Cannot be 


Can be 


Can be treated 




treated at all 


managed 


successfully 


Depression 


0.0 


60.7 


39.3 


Addiction to alcohol 


0.0 


55.4 


44.6 


Diabetes 


0.0 


84.9 


15.1 


Asthma 


0.0 


84.2 


15.8 


Addiction to drugs other than nicotine or alcohol 


0.0 


57.6 


42.4 


Heart disease 


2.2 


75.5 


22.3 


Addiction to nicotine 


0.7 


40.6 


58.7 



2. Which of the following do you think are the main factors involved in developing. . . 

(i) Addiction to tobacco? (Please select a maximum of two primary factors) 

(ii) Addiction to alcohol? (Please select a maximum of two primary factors) 

(iii) Addiction to prescription/illegal drugs? (Please select a maximum of two primary factors) 









Addiction to 




Addiction to 


Addiction 


prescription 




tobacco 


to alcohol 


illegal/drugs 


A physical health problem 


36.2 


40.4 


45.4 


A mental health problem 


19.1 


46.8 


45.4 


A genetic problem 


18.4 


64.5 


38.3 


A behavioral problem 


47.5 


50.4 


48.9 


A moral problem 


10.6 


30.5 


24.1 


A spiritual problem 


12.1 


41.8 


32.6 


A reliance on the substance as an emotional crutch 


53.9 


81.6 


66.7 


A problem of willpower or self control 


29.8 


26.2 


19.1 



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3. What should be a treatment provider's main treatment goal for. . . * 

(i) Someone addicted to tobacco? 

(ii) Someone addicted to alcohol? 

(iv) Someone addicted to prescription/illegal drugs? 



"The survey allowed respondent to choose more than one option for this question. 









Addicted to 




Addicted to 


Addicted 


prescription 




tobacco 


to alcohol 


illegal/drugs 


Complete abstinence from the substance 


48.2 


70.2 


65.2 


Reduced use of the substance 


21.3 


9.2 


9.2 


Fewer negative consequences from use of the 








substance 


11.3 


9.2 


9.9 


Goal should be set by the patient 


41.1 


22.0 


26.2 


Other 


6.4 


3.5 


5.7 



4. In your opinion, where should the money come from to pay for treating substance abuse and 
addiction? (CHECK UP TO THREE SOURCES) 

If a source that you think the money should come from is not on the list below, please check 

"Other" and write in your answer. 

18.4 General tax revenues (e.g., income tax) 

48.2 Increased taxes on alcohol 
42.6 Increased taxes on cigarettes 

54.6 Fines for individuals driving under the influence of alcohol or other drugs (DUIs) 

33.3 Fines for commercial establishments that sell alcohol or cigarettes to minors 

20.6 Funds saved from cutting government spending in other areas 

39.7 Private insurance 

28.4 Self-pay 

9.9 Other (PLEASE SPECIFY) 

II. ATTITUDES TOWARD TREATMENT 

5. How important is it for a treatment facility to have each of the following comprehensive 



assessment services available to clients/patients? 





Not at all 


Slightly 


Moderately 


Very 




important 


important 


important 


important 


Substance use behavior 


0.0 


0.7 


1.4 


97.9 


Other mental health conditions 


0.7 


0.7 


7.9 


90.7 


Other physical health conditions 


0.7 


3.6 


29.5 


66.2 


Family history of substance use 


0.7 


3.6 


20.7 


75.0 


Social/peer history of substance abuse 


0.7 


4.3 


28.1 


66.9 


Family/social network support systems 


0.0 


2.2 


15.1 


82.7 


Economic circumstances 


1.4 


14.4 


40.3 


43.9 


Religious/spiritual involvement 


1.4 


15.0 


42.9 


40.7 



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How important is it for a treatment facility to have each of the following interventions/therapies 
available to clients/patients? 





Not at all 


nr i , i 

Slightly 


Moderately 


Very 




important 


important 


important 


important 


Detoxification 


3.6 


10.9 


18.1 


67.4 


Motivational interviewing 


0.7 


7.2 


27.5 


64.5 


Cognitive behavioral therapy 


0.0 


2.2 


23.2 


74.6 


Family therapy 


0.0 


3.6 


35.5 


60.9 


Religious/spiritual interventions 


7.9 


23.7 


43.2 


25.2 


Mental health management (offered 


0.0 


1.4 


14.5 


84.1 


along with substance abuse treatment) 










Medical treatment for conditions such 


2.2 


11.6 


29.7 


56.5 


as Hepatitis C, HIV, TB, STDs, and 










other chronic medical illnesses (offered 










along with substance abuse treatment) 










Pharmacology therapies 


Methadone maintenance for 


7.9 


27.3 


30.9 


33.8 


addictive disorders 










Other pharmacological 


2.2 


22.5 


29.7 


45.7 


interventions for addictive disorders 










(e.g., buprenorphine, disulfiram, 










naltrexone) 










Pharmacological interventions for 


0.7 


5.8 


20.9 


72.7 


co-occurring mental health 










conditions 










Pharmacological interventions for 


4.4 


19.0 


38.7 


38.0 


pain management 










Complementary/ alternative medicine 


2.9 


24.5 


37.4 


35.3 


approaches, such as acupuncture, 










meditation 










Recreation therapy/leisure skills 


0.7 


14.4 


30.2 


54.7 



training 



How important is it for a treatment facility to offer each of the following? 

Not at all Slightly Moderately Very 
important important important important 



Transportation services 


2.2 


23.0 


32.4 


42.4 


Child care services 


6.5 


23.9 


33.3 


36.2 


Employment/vocational services 


2.2 


7.2 


27.3 


63.3 


Housing services 


4.3 


17.4 


26.8 


51.4 


Referral to programs such as AA, 


2.2 


4.3 


13.8 


79.7 


Narcotics Anonymous, SMART 










Recovery 










Recovery support programs (e.g., AA, 


1.4 


5.0 


20.9 


72.7 


Narcotics Anonymous, SMART 










Recovery) 










Relapse prevention (e.g., long-term 


0.0 


2.2 


11.5 


86.3 



case management) 



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8. Which one of the following types of professionals do you think is best qualified to provide 
addiction treatment services? 

72.6 Substance abuse counselors 
17.8 Social workers 

0.7 Nurses 

6.7 Psychologists 

1.5 Physicians 

0.7 Persons who are recovered addicts or recovering from addiction 

9. Do you think that only graduate-level clinicians/staff should provide addiction treatment services 
while non-graduate-level substance abuse counselors provide recovery support services OR do 
you think that non-graduate-level clinicians/staff should provide both addiction treatment services 
and recovery support services? 

Note: 

Graduate level clinicians/staff refers to those with degrees/qualifications such as the following: 
MD, PhD, MA, RN, NP. 

Addiction treatment services refers to services such as the following: cognitive/behavioral 
therapy, pharmacotherapy. 

Recovery support services refers to services such as the following: connection to mutual support 
programs; legal, housing, other social and health services; providing social support. 

35.6 Only graduate-level professionals should provide the actual treatment, while counselors 

provide recovery support service 
64.4 Non-graduate- level clinicians/staff should provide actual treatment and recovery support 

services 

10. How important do you think it is for addiction treatment clinicians/staff to have each of the 



following qualifications? 





Not at all 


Slightly 


Moderately 


Very 




important 


important 


important 


important 


Personal experience with addiction 


23.7 


36.0 


21.6 


18.7 


College degree (e.g., BA/BS) 


12.9 


19.4 


40.3 


27.3 


Master's degree (e.g., 


18.8 


23.2 


31.9 


26.1 


MA/MS/MPH/MSW) 










Doctoral degree (e.g., PhD/DSW) 


43.9 


28.1 


21.6 


6.5 


Medical degree (e.g., MD/DO) 


41.7 


24.5 


20.1 


13.7 


Specific training in addiction treatment 


0.7 


0.7 


7.9 


90.6 



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If training were offered, which one or two training topics would be most helpful to you 
personally? (CHECK UP TO TWO RESPONSES) 

17.0 Diagnosis/assessment via interview 

7.8 Using standardized screening instruments 

21.3 Etiology and prevalence of co-occurring disorders 

1 7.0 Preferred treatment practices 

25.5 Motivational interviewing 

24.8 Specialized group treatments 

12.8 Pharmacological treatments 

19.9 Assertive case management approaches 
7.1 Specialized 12-step facilitation approaches 

35.5 Individual/group psychotherapies 

3.6 Other (PLEASE SPECIFY) 



Which of the following describes your opinion on the best way to structure the delivery of 
substance-addiction treatment in the U.S.? (CHECK THE ONE THAT BEST APPLIES) 
8. 1 The system should be integrated into the medical system such that addiction is treated as a 

health condition by heath care professionals (GO TO #14) 
21.3 The system should revolve around a recovery support model, with self-help/mutual support 

programs as the main intervention (GO TO #14) 
60.3 The system should be two-tiered with health care professionals providing 

psychotherapeutic and pharmacological interventions and individuals in recovery providing 

recovery support services (GO TO #14) 
10.3 Nothing should change 



Why did you say that nothing should change? (Those who answered "Nothing should change" in Q12) 

28.6 Because the system is structured in the best possible way 
0.0 Because a change in the way that treatment for addiction is delivered would be too costly 
7. 1 Because change in the way that treatment for addiction is delivered would be too disruptive 

to individuals involved in treatment recovery 
7. 1 Because we do not know how to change the treatment system 

57.1 Other reason 



To what extent does each of the following stand in the way of people looking for needed 
treatment for addiction/substance abuse? 





Not at all 


Somewhat 


Very much 


Denial of an addiction problem 


2.9 


12.2 


84.9 


Belief that treatment does not work 


9.4 


59.0 


31.7 


Fear that one will be discriminated against if 


18.1 


51.4 


30.4 


looking for treatment 








Fear of losing child custody (to the state or to 


4.3 


37.0 


58.7 


another individual competing for custody) 








Fear of losing job 


5.8 


38.4 


55.8 


Fear of being sent to prison or jail 


20.3 


42.8 


37.0 


Inability to pay /lack of or insufficient medical 


6.5 


42.8 


50.7 


insurance 








Waiting lists that are too long 


29.7 


49.3 


21.0 



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15. To what extent does each of the following stand in the way of people receiving needed treatment 
for addiction/substance abuse? 

Not at all Somewhat Very much 
Lack of a treatment facility that is conveniently 21.6 56.8 21.6 

located 

Lack of a treatment facility providing services that 18.0 56. 1 25.9 

are suited to the individual client's needs 

Lack of ability to pay for treatment (including lack 7.9 32.4 59.7 

of private sources of funds and/or insurance 

coverage) 



16. To what extent does each of the following stand in the way of treatment providers in New York 
State's ability to provide effective services to people in need of addiction/substance abuse 
treatment? 





Not at all 


Somewhat 


Very much 


msuriicient program funding 


2.9 


33.8 


63.3 


Insufficient insurance coverage tor clients/patients 


3.6 


34.8 


61.6 


Insumcient salaries to attract and retain high- 


4.3 


25.9 


69.8 


quality staff 








T CC A. 1 J? J. * J 1 

Insufficient number of trained counselors 


15.1 


51.1 


33.8 


(CASACs) 








Insufficient number of trained Master s-level 


35.3 


43.9 


20.9 


professionals 








Insufficient number of trained PhD-level 


CO H 

58. / 


1 A 1 

34.1 


1 .1 


professionals 








Insufficient number of trained MD/DO-level 


44.2 


42.8 


13.0 


professionals 








Insufficient number of appropriately trained staff 


8.6 


54.0 


37.4 


with the qualifications necessary to provide 








treatment for co-morbid physical or mental health 








conditions 








Insufficient number of appropriately trained staff 


19.0 


61.3 


19.7 


with the qualifications necessary to provide 








pharmacological therapies 








Insufficient federal- or state-level education and 


30.4 


46.4 


23.2 


training requirements for individuals providing 








addiction treatment 








Insufficient professional standards related to 


35.5 


42.8 


21.7 


knowledge and clinical skills for individuals 








providing addiction treatment 








Limited motivation among staff members to be 


25.5 


54.7 


19.7 


knowledgeable about evidence-based best practices 








Insufficient access to information about best 


34.8 


49.3 


15.9 


practices 








High volume of paperwork (reporting requirements 


2.9 


24.5 


72.7 



that take up too much time and resources) 



-290- 



17. How important do you think it is that there be national standards for how addiction/substance 
abuse treatment services should be delivered to patients/clients? 

4.3 Not at all important (GO TO #19) 
15.1 Slightly important 

29.5 Moderately important 

51.1 Very important 

18. Which of the following would be in the best position to decide on such national standards for the 
delivery of addiction/substance abuse treatment services? (CHECK THE ONE THAT BEST 
APPLIES) 

13.7 The federal government 

33.6 National professional organizations 

38.2 State professional organizations 
14.5 Other (PLEASE SPECIFY) 



III. EVALUATION 



19. What are the three main ways your program evaluates how well it is doing? (CHECK UP TO 
THREE RESPONSES) 

2.8 Our program does not conduct evaluations (GO TO #20) 

24. 1 Informal reports of staff perceptions 
48.9 Random client feedback/testimonials 

3 1 .2 Drug test results 

59.6 Program completion rates 

2.8 Reduction in use based on self- report of clients only 

19.9 Reduction in use based on self-report of clients AND information from other sources 
2.8 Abstinence from use based on self-report of clients only 

34.8 Abstinence from use based on self-report of clients AND information from other sources 
0.7 Remission of symptoms based on self-report of clients only 

18.4 Remission of symptoms based on self-report of clients AND information from other 
sources 

0.0 Reduced recidivism rates for criminal offenders based on self-report of clients only 

22.0 Reduced recidivism rates for criminal offenders based on self-report of clients AND other 
information from justice departments 

20. At what stage(s), if any, in the treatment of an individual patient, does your program assess how 
well treatment is working? (CHECK ALL THAT APPLY) 

7.8 Our program does not assess how well treatment is working (GO TO #21) 

43.3 At treatment program exit 

27.7 One month after treatment 

41.1 2 to 6 months after treatment 

14.9 7 to 12 months after treatment 

12.8 More than one year but less than five years after treatment 
2. 1 Five years or more post-treatment 



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21. In your opinion, what are the three primary ways a program should assess its effectiveness, 
assuming that a program has sufficient resources for this? (CHECK UP TO THREE 
RESPONSES) 

2.8 Program effectiveness does not require evaluation 
16.3 Informal reports of staff perceptions 

46. 1 Random client feedback/testimonials 

29. 1 Drug test results 

55.3 Program completion rates 

1 .4 Reduction in use based on self-report of clients only 
21.3 Reduction in use based on self- report of clients AND information from other sources 

2. 1 Abstinence from use based on self-report of clients only 

53.2 Abstinence from use based on self-report of clients AND information from other sources 
0.0 Remission of symptoms based on self-report of clients only 

32.6 Remission of symptoms based on self-report of clients AND information from other 
sources 

0.0 Reduced recidivism rates for criminal offenders based on self-report of clients only 

21.3 Reduced recidivism rates for criminal offenders based on self-report of clients AND other 
information from justice departments 

IV. WORK ENVIRONMENT 

22. In a typical day, about how many hours do you work at the treatment facility? 

2.1 1 to 4 hours 

44.3 More than 4 hours to 8 hours 

50.7 More than 8 hours to 12 hours 

2.9 More than 12 hours 

23. In a typical day, about how many total hours a day would you say you spend on each of the 
following tasks? 

If you perform any other task in a typical day on which you spend one or more hours but that task 
is not on the list below, please specify the task and indicate how many hours you spend on it. 

3.2 Seeing/counseling/treating clients face-to-face 
1 . 1 Working with clients over the phone/via email 
0.8 Tracking clients because of missed appointments 

1 .4 Finding and scheduling referral services for clients 
3 . 1 Completing paperwork 
2.7 Other (PLEASE SPECIFY) 

24. From the list below, please select the top two things a client might do that would keep you from 
doing your job well. (CHECK UP TO TWO RESPONSES) 

57.4 Miss appointments 

33.3 Never return after initial visit 

32.6 Fail to follow treatment plan 

41.1 Lie about behavior 

12. 1 Spend time with you just chatting instead of working with you 

7.1 Other (PLEASE SPECIFY) 



-292- 



25. From the list below, please select the top two factors that mainly motivate you to keep you doing 
your job. (CHECK UP TO TWO RESPONSES) 

73.0 The work is rewarding 
29.8 The work is enjoyable 
15.6 I like my colleagues 
34.0 I like my clients 

2. 1 The pay is good 

5.0 The hours are good 

5.0 The benefits are good 

2.8 No other jobs are available 

15.6 I made it out of addiction and consider it my responsibility to help others 

6.4 Other (PLEASE SPECIFY) 

26. If you were to leave your job, what are the top two reasons you would do so? (CHECK UP TO 
TWO RESPONSES) 

42.6 I do not plan to leave my job 

17.7 The work is frustrating 

5.7 I dislike my colleagues 
0.0 I dislike my clients 

47.5 The pay is too low 

8.5 The hours are not good 

10.6 The benefits are not good 

0.7 I made it out of addiction and do not want to deal with this issue anymore 
28.4 Other (PLEASE SPECIFY) 

V. RECOMMENDATIONS 

27. Given sufficient resources, what are three ways you would change your program to improve 
treatment quality at your facility? 

9.6 Higher pay/incentives for staff 

9.3 Improve facilities/more space and activities 

9.0 Hire more qualified staff 

8.7 Spend more time with clients/lower caseloads 

8.3 Decrease paperwork/improve efficiency in process 

8.3 Provide more training/education to staff/team 

6. 1 Provide more resources for client (child care, transportation, etc.)/case management 

5.8 Insurance coverage/funding 

5.8 Eliminate/add treatment, effective treatment 

5.4 Better counselors, more specialized for cultural/language differences 

2.9 Customized services for women/children/families 

2.6 Better materials/services/procedures (quality assurance) 
18.3 Other (PLEASE SPECIFY) 



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28. Given sufficient resources, what are three ways you would suggest for improving the treatment 
system for addiction or substance abuse in New York? 

1 1 .4 Case management services (housing, job training, child care, etc.) 

9.6 Uniform system/less paperwork 

8.9 Better education/training system for providers 

8.6 Effective/more proven treatments, customized/quality treatments 

7.5 Incentives for workers/providers, higher pay 
6.8 Affordable healthcare/insurance 

6.4 Better funding/cut costs 

5.7 Improve availability of programs, more time with clients 
5.4 Women/family/children customized treatment 

5.0 Hire more qualified staff 

24.6 Other (PLEASE SPECIFY) 

V. INDIVIDUAL DEMOGRAPHICS OF STAFF MEMBER PARTICIPATING IN THIS 
SURVEY 

29. In what year were you born? 
17.9 Before 1950 

32.1 1950-1959 

25.4 1960-1969 

16.4 1970-1979 
6.0 1980-1989 

2.2 Other (PLEASE SPECIFY) 

30. Are you Hispanic/Latino/Latina or of Spanish origin? 
14.1 Yes 

85.9 No 

3 1 . Which racial or ethnic group do you identify? 

63.0 White 

21.5 African American 

0.7 Asian American/Pacific Islander 

0.7 Native American 

14.1 Other 

32. What is your gender? 
39.4 Male 

60.6 Female 

33. What is the highest level of education you have completed? 

0.7 Less than high school graduation (Go to #35) 

6.6 High school graduate or GED (Go to #35) 
29.9 Some college or associate degree (Go to #35) 

27.7 Four-year college degree (Go to #35) 
35.0 Graduate or postgraduate degree 



-294- 



34. What is your professional title? (Check the ONE that best applies) 

0.0 Physician 

4.2 Psychologist 

0.0 Physician Assistant 

0.0 Nurse Practitioner 

0.0 Registered Nurse 

0.0 Licensed Practicing Nurse 

41.7 Social worker 

12.5 Addictions counselor 

41.7 Other* (PLEASE SPECIFY) 

* A significant proportion of those who responded with the "Other" option specified that 
they are some form of addiction counselor or that they define themselves as both an 
addiction counselor and another professional title. 

35. Do you have specific training in addiction treatment or do you not? 
93.5 Have specific training (PLEASE SPECIFY) 

6.5 Do not have specific training 

36. How many years of experience do you have in the field of addiction treatment? 

1.4 Less than 1 year 

5.8 1 year to less than 2 years 

14.4 2 years to less than 4 years 

10.1 4 years to less than 6 years 

12.9 6 years to less than 9 years 

5.0 9 years to less than 10 years 

50.4 10 years or more 

37. On average, how many clients are on your treatment caseload at any point of time? 

5.1 1-5 
15.9 6-10 

13.8 11-15 
9.4 16-20 

22.5 21-30 
9.4 31-40 

7.2 More than 40 

16.7 I do not carry a caseload 

38. Do you think that being a recovered addict or recovering from addiction should be a prerequisite 
for being a treatment provider, or should it not? 

23.0 No, it would not help the position and should not be a prerequisite 

71.9 It might help but should not be a prerequisite for the position 
5.0 Yes, it would help and it should be a prerequisite 



THANK YOU! 



-295- 



-296- 



Appendix F 

National Panel and National Online Survey of Members of 
Professional Associations Involved in Addiction Care* 



National Panel of Treatment Providers 

Beauchemin, Patricia, Executive Director, Therapeutic Communities of America f (TCA) 

Budney, MD, Alan J., Professor of Psychiatry and Research Scientist, Center for Addiction Research, 
University of Arkansas for Medical Sciences (American Psychological Association - APA) 

Femino, MD, John, Medical Director, Meadows Edge Recovery Center (American Society of 
Addiction Medicine - ASAM) 

Fleming, MPA, LSAC, Patrick J., Director, Salt Lake County Division of Substance Abuse Services 
(National Council for Community Behavioral Healthcare - National Council) 

Grant, Linda, Executive Director, Evergreen Manor (State Associations of Addiction Services - SAAS) 

Greer, Patricia M., President, National Association of Alcoholism and Drug Abuse Counselors - 
NAADAC* 

Hurt, MD, Richard D., Director and Professor of Medicine, Nicotine Dependence Center, Mayo Clinic 
College of Medicine (Association for the Treatment of Tobacco Use and Dependence - ATTUD) 

Marion, MA, Ira, AATOD First Vice President and NYS Board delegate and Executive Director, 
Albert Einstein College of Medicine (American Association for the Treatment of Opioid 
Dependence - AATOD) 

Mumbauer, Daniel, President and Chief Executive Officer, Southeast Regional Network, Highpoint 
Treatment Center (National Council for Community Behavioral Healthcare - National Council) 

Olsen, LCSW, CASAC, SAP, Edward, Director, EAC Outpatient Clinic (National Association of 
Alcoholism and Drug Abuse Counselors, NAADAC) 

Roy, III, MD, A. Kenison, Fellow, American Society of Addiction Medicine; Distinguished Fellow, 
American Psychiatric Association; Assistant Clinical Professor of Psychiatry, Tulane Medical 
School; and Medical Director, Addiction Recovery Resources of New Orleans (American Society 
of Addiction Medicine - ASAM) 

Schwarzlose, John T., President and Chief Executive Officer, Betty Ford Center (National 
Association of Addiction Treatment Providers - NAATP) 

Scimeca, MD, Michael M., Area II Director (American Academy of Addiction Psychiatry - AAAP) 



Names and titles of individuals and organizations represent those at time of Panel. 
This organization currently is named Treatment Communities of America (TCA). 
This organization currently is named NAADAC, the Association for Addiction Professionals. 



-297- 



Washton, PhD, Arnold M., Founder and Executive Director, Recovery Options (American 
Psychological Association - APA) 

Whitman, MS, Ellen G., Executive Director, National Association of County Behavioral Health and 
Developmental Disability Directors - NACBHDD 

Wilkins, Christopher R., Senior Vice President, DePaul Addiction Services (State Associations of 
Addiction Services - SAAS) 



-298- 



National Online Survey of Members of Professional Associations Involved in 
Addiction Care 

Responses from 1,142 survey participants. The number corresponding to each response option represents 
the percent, among those responding to the question, that provided the particular response. 

1. To what professional organization do you belong? 

9.9 American Academy of Addiction Psychiatry (AAAP) 

2.7 American Association for the Treatment of Opioid Depe